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Waste Tire SuQey & Inspection Reporp Inspection Report Number <br /> State rnia Survey Form Page 1 I 0 4 $ 2 0 <br /> ClWMB IWMB 18181(Now 04104) . ■ <br /> California Integrated Waste Management Board <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Dotal is T <br /> TPID- f Inspection Type (Fill one) <br /> Site Suffix: 1 u 3 7Q �� ,.� - , ,® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> l�ww►r�- L�� va�Cc ��I� FII_C4� <br /> Physical Address <br /> Z t <br /> CAInspection Date "7— <br /> Time In Time Out <br /> Business Rep Title O AM , 0 AM <br /> 0 PM 0 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)f (Fill all that apply); <br /> f ' ®Active ® Passenger 1@) Generator Outdoor <br /> a 0 Closed Q' Altered GPS Latitude I 0 Hauler 0 Indoor <br /> o 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer V) Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> i <br /> ,-i/'. ,�,, �; •�/ice:j/.i., <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> "s / �f� /// / � // /.i ✓/ <br /> J /;: %/, �•/ ,./, / ,. �,-�:f ,'.,�� ...��//,,�lr. ...,r.,'//!•:' �'/l//ice.✓ �;: . <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 ® 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 00 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities J /f <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators �� y <br /> 0 0 Other: § <br /> Comments <br /> Imo.. -- - • <br /> Inspection Form Included; <br /> Comments Included; - — - <br /> _ _0 Bus15 <br /> s Rep's Sign to a Phone umber Inspect 's Bignatu Phone Number <br /> Alq✓ w.�cr, : 62081 <br /> INSTRUCTIONS ON BACKF. , P f �C IWi. P I. 112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />