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Waste Tire Survey & Inspection Re 'ori . Inspectio,Report Number <br /> p p <br /> State of IW81California Survey.Form - Page..1. 1 9 - •1 0 0 -6 5 2.4 <br /> CIWMB Tat(New 04/04) <br /> California Integrated Waste Management Boats .. <br /> Part A Survey _ BLUE OR BLACK INK PEN <br /> Business Profile, Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l Routine Q Re-inspection Q Referral Q Observation, <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB p Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - --- <br /> Inspected By Inspector <br /> Physical Address 3 <br /> Oy�OK\�U <br /> Inspection Date <br /> c 5 5 ao5 <br /> Time In Time Out <br /> Business Rep AAAA 11 Title (r�� 0 AM 0 AM� t� 0 PM 0 PM <br /> operational Status Tire Type' Business Role Storage Type <br /> Tire Count(Whole/PTE) �.` C (Fill one only) (Fill all that apply) (Fill all that apply) -(Fill all that apply) <br /> 0 Active Q Passenger !Generator a Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude - � Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned •OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 �i1„Q,�,p _ .. <br /> Part B-Inspection of Waste Tire Dealer Generator,Hauler and End-Use Facility <br /> MOOD <br /> Q O 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 Y? <br /> Q Q +14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB y y sti <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 a <br /> Q Q 14 CCR§18460.2 Manifest System Requirements for Registered Waste Tire Haulers <br /> a <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q b 14 CCR§.18482-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 1 Q <br /> Other: $ <br /> Comments 1 <br /> 1 <br /> �p 7nsm�✓1 A �n/�`Su,n�n/.i �.rp ChayrN� All T1Vt� V�fD li <br /> 40k&6-MA- 14,rt[ tP- Entered <br /> KS <br /> Inspection Form.included: <br /> Comments Included: <br /> i Business Rep's Signature Phone Number s s,S' at Phone Number <br /> `M ; 62081 . <br /> INSTRUCTIONS ON BACK . , F ,` _f ; E X M P E 1 2 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0529204.0828 <br />