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=L= Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateof181(New <br /> Survey Form - Page 1 1 9 - 1 4 1 3 1 6 5 <br /> CNYMB lel(Naw 114106) <br /> camomia Integrated Waste Managemsm Boerd <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> inspection Details <br /> Business Profile - Pe�� _ <br /> TPID• �t Inspection Type (Fill one) <br /> slte sufri / 0 y f S 9 -Z o / <br /> � _ *Routine Q Re-inspection Q.Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sa-"L �pQ,ite.. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 9 <br /> 3 75-4— & bt/� Z-,L _ <br /> �,� � �SVWY Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> A'7S4'4�cC O PM — O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body .Car Dealer Q Collection Q Crumb Rubber <br /> L�Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q 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 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 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 <br /> Q Q 1 Other: <br /> Comments f <br /> 4U41,7.Q <br /> Inspection Form Included:WI. <br /> Comments Included: 37signature . Phone Number Inspector's Signature Phone Number - <br /> INSTRUCTIONS ON BACKE A IA4 P i 1 2 3 62081 <br /> ■ White Copy:CIWM6 Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0705964.0323 <br />