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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWM of 81 New Survey Form - Page 1 1 4 - 1 0 2 5 7 0 1 <br /> CIWMB 1B1 New 04704) <br /> California Integrated Waste Management eaard <br /> Part A- Spry" _ BLUE OR BLACK INK PEN <br /> Business Profile r Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: 1 .2— - f 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: \)oaf}rt �� yIEV�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> � ?"` ' z <br /> Physical Address > t Q t 7zi, <br /> �A. � �33 I Inspection Date 0 -2- <br /> } 6 Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM O PM <br /> Operational Status Tire Type I 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 /> f t 0 Active Q Passenger Q Generator J Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude _ Q Planned Q 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 <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility MIXITATUS <br /> fill <br /> ow <br /> Q 1 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ytt}Iativn nqa <br /> o . Q PRC§42953-Contracts with Registered Waste Tire Haulers. 09 <br /> f - <br /> 00 <br /> 'PRC§42956-Registration/Decal in Vehicle <br /> Q o 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ' j <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWM6 f <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days �� ,, � � . <br /> Q o 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q o 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities -mow ;. - `�• r - -_ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 10 Other: § ! <br /> Comments N a: feem, T/ �! �C r / a�("!.✓ ,R t'd45 y <br /> cv�n�c �^a t•.� ���� wa sE4��� . <br /> ` Z P1 D* <br /> 5�t" + �-1 W/�/l_$_. 1n/•� 1 tic �,� �.�cv�-�'. <br /> Inspection Form Included: Q BusComments included: 7� <br /> Igatureines nPh <br /> Number _ec Ignatur Phone Number <br /> ,i �It 62081 <br /> N W <br /> INSTRUCTIONS ON BACK �_ 0/j3illi P L <br /> White Copy:CiWM6 Yellow Copy,Operator Pink Copy:LEA <br />