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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r State of California <br /> CIWMB IB„New gaSurvey Form — Page 1 1 1 1 0 0 �!V ! 1 5 <br /> ifornia Integrated Waste Management ment Board <br /> Part A-Surve _ _ _ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TIMID- inspection_ D , inspection Type(Fill one) <br /> Site Suffix: \ IF7 <br /> e 0 Re-inspection Q Referral Q Observation <br /> Lel p B Referral,choose referral type(Fill one) <br /> ..Identifier '5o hk \,O Q CHP Q CIWMB Q Complaint Q Educational Visit <br /> Q Other <br /> Busihess or Facility Name <br /> _ Inspected BY Inspector <br /> SwC.-� 1 <br /> Physical Address � — <br /> °� 1 b <br /> st— <br /> Inspection DateD C <br /> Time In Time Out <br /> Business Rep Tide @- O AM !1 0 AM <br /> S C.7 3 ' l 'J 0 PM C, 3 l 0 PM <br /> Operational Status -Tire Type ype 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 ®Passenger ®Generator Q Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude _ Q Planned ®OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> ®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 0 Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 1. .p . �.yy,,, ✓F4��i''�i+c&�:.fR R =...� Y'� � .C3.Y�;2� 4' ��„��i';Y`' <br /> 0 0 PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. r <br /> Q Q PRC§42956-Registration/Decal in Vehicle •rx�� < y <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 /> 0 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 r' �' £ <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 Other: § <br /> Comments �`` �SIS � V►rQ r..r- .7s.D 1 <br /> W.6\,- `.�t�q �. —c�� l..sw� _ '2`-r-(- o S _ � �en,a <br /> Inspection Form Included:Q pip R <br /> Comments <br /> B sl s ep's gnature Phone Number Inspe ot'sSiBnatu►e Phorit3 Number <br /> INSTRUCTIONS ON BA K �`n���"�M y y� <br /> !: br+ z * w a X rsr P 62081 <br /> . - - White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA <br /> 0529204. 1057 <br />