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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r State of Califomia <br /> CIWMB 18ast(Now Manage Survey Form - Page 1 1 7 - 1 01 3 6 3 4 <br /> Callfomla Integntad Waste Manepentenl Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - <br /> TPID- Inspection Type (Fill one) <br /> site suffix: l y 3 7 8 6 g - () j <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB QCom Complaint Q Educational onal visitQ Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspect r <br /> Ce n4- <br /> Physical Address <br /> N1.2- GL ,a'1 h ae /0�1 vc - - — - - <br /> Inspection Date O bl <br /> 7 Time In Time Out O <br /> Business Rep Title fa AM �/ AM <br /> �C / RXIGcC� Qlf I �� O PM / / Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Fill <br /> ( one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f r PP Y) <br /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered q/ <br /> GIPS Latitude O Q <br /> O Q Inactive 0 Truck Hauler Q Indoor 'r <br /> Longitude - Q Planned Q OTR O 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 0 Dismantler 0-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 •Other ��`1 / <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility 7 <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts With Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entitles 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§18459-2.1-Submittal of Manifest Farms 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 <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 1 Q 1Other: § 11 <br /> Comments -ay"Qi" /. ., k �/___ /�4',rGf �+t �►�/ . <br /> F42W4; �A ate 4% wo-It- <br /> A4 t4e Q � krr� �Ca��a,� coact,.' At tae. Acrak,,. <br /> 5100f r7 n ! <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Bus as Rep' Ignature Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0619404.0053 <br />