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�= Waste Tire Survey P P& Inspection Report Inspection Report Number ■ <br /> Cali <br /> State 'Wr°mia Survey Form - Page 1 1 6 - 1 0 0 6 7 4 3 <br /> cIWMa 1B1(Ne w 04/04) <br /> California IntegrateeddWaste Management Board <br /> Pati A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspectioft Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: i O 3 0 0 , 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier:. �aw C <br /> p of � t,1N1rT � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> G111 T _ <br /> Physical Address l� .3 ` l �'•'�'A.y„ G lr�-w�� <br /> - <br /> �� Inspection Date / ; / C> <br /> S�bcLc�o <br /> Time In Time Out <br /> Business Rep Title 9 AMQ AM <br /> O PM � � Z O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tlf@ Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r r ®Active 0 Passenger e Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> O Q Inactive Q Truck. <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> le New Tire Dealer Q Auto Repair .Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> — I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O I O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 daysr <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 yearsit � <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire.Haulers " n <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End�Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators + f •f <br /> v <br /> 101 O § <br /> Other• <br /> c ` - 1 ( WW <br /> Comments i` 5 YWDI 0\1,-S tit- _f Ci 15 o't--Cbo j y L-5t <br /> Val I vc�(,vr.lµ�S w owtrn+r. <br /> �, � S w ilio vidia�icx.5. <br /> Inspection Fonri.Included:. <br /> Comments Included:O. "VL <br /> Bu Rep' Signature Phone Number -Ins or s.'Signature Phone Number- <br /> INSTRUCTIONS.ON BACK 62081 <br /> ■ ,Copy: p � X k IAA L S E 1 � 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LFA ■ <br /> 0529204.1050 <br />