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== Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of CalHornia <br /> ClWMB1G1(New04104) Survey Form - Page 1 l 3 - 10 Z 5 76 6 <br /> California Integrated Waate Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 'Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> 6 Site Suffix: 1 � �j- 7 r > IS Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ( ! - 0 \'511tt � <br /> '�scaS,s� CA <br /> Inspection Data p 5> p <br /> Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> 0 P 0 P <br /> Operational Status Tire Type Business Role I Storage Type <br /> (Fill one only) , (Fill all that apply) (Fill all that apply) I (Fill all that apply) <br /> Tire Count (Whole/PTE) 55 <br /> f f 4j Active ®Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q 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 /> t 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility EH. meNT_ TATUS.. <br /> - <br /> V: A: HAULING AND MANIFEST R0211.11RAME?NTS O rotlde Violaon Q Extension <br /> O O j PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. CortpintQ Qaadll�te <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements l7pt <br /> 14 CCR 18459.1 a b c -Tire Program ID Number from CIWMB <br /> . <br /> O O § OOO 9 <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (F�e4u(redPrNOV!EMX7� <br /> O O �s <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - <br /> i . <br /> O O 14 CCR§18460,2-Manifest System Requirements for Registered Waste Tire Haulers . � H IEnforesm <br /> ant <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ` V i <br /> pit nom - No Vial In <br /> O O Other: § - 1 <br /> Comments - - - cAle /� Yty� — — -ft0T�. <br /> r - - <br /> /Vv 1/w V mr/ /n/tv/ Cvn e_ rrt - <br /> ,Inspection Form Included: Q r <br /> Comments Included:Q � <br /> f Business Bp's i ure Phone Number Phone Number <br /> INSTRUCTIONS ON BACK Cetrtct, _li1tP+� � X AAh�1P i L E 0 62081 <br /> Entered While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> KB <br />