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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of <br /> ClWM Survey Form - Page 1 17 . 1 0 0 6 $ 0 <br /> CIWMB 781(New 04!04) <br /> Celifomla Integratetl Waste Management Board <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details. <br /> TPID- Inspection�y ' a 8 _ O Inspection Type (Fill one) <br /> Site Suffix: l(/ D Q Routine Q Re-inspection Q Referral Q Observation <br /> Localn If Referral,choose referral type(Fill one) <br /> Identifier: `1�^yt t� C(�,(A,j J l I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FaciliNNtv Name (/J - <br /> ter e S I Inspected By Inspector <br /> Physical Address 3 Q ( � � �✓a <br /> / Inspection DateTrQ([j Time In <br /> Time Out <br /> Business ReTitle O AM <br /> O AM <br /> LWn JCS <br /> -koNu'u+'vK. O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) fj (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f , ®Active Q Passenger Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive �Truck <br /> Longitude _ Q End-Use Q Container <br /> Q Planned Q OTR <br /> BuslnessType (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 I, 1 <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 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 /> Q Q 14 CCR§111459.2.1-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 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 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 10 1 Other: § <br /> Comments ��j p p j per' AS - 'Av <br /> c RJdS <br /> c <br /> ham" to 1 i1'4oV I_ ��ne Dr W�� - rC'.(r�tel'✓f Ca <br /> - � ���er�• � ✓� ens �f.� - <br /> Inspection Form Included:Q� <br /> Comments Included:Q <br /> Business Reps Signature Phone Number �sp ctor's nature Phone Number <br /> INSTRUCTIONS ON BACK 1E1IM P E111213162081 <br /> ■ 0716504.0040 White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />