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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 1 2 - 1 Q Q 6 7 2 4 <br /> crvvnt6 tat(rtaw oatoa) <br /> Califomla Integrated Waste hlanagemant Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile - - -- - Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> SRO Suffix: b p2 / � / 0 Routine Q Re-inspection 0 Referral Q Observation <br /> Local / n If Referral,choose referral type(Fill one) <br /> Identifier. Q.t1- ,v/ p��,H GQ Q CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name f! <br /> Inspected By Inspector <br /> Physical Address <br /> /3 Inspection Date D <br /> Time In Time Out <br /> Business Rep Title AMAM <br /> �J�J O PM � � � ",Q' QPM <br /> �✓l!/ t1� d �a�cT /„ <br /> operational Status TlreType 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 r 0 Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Retreader O Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body O Car Dealer O Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler I@ Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Not'sae t}f Y( z <br /> �PRC§42951-Waste Tire Hauler Registration and Transport of Tires alatdon 0 E*tensto�t <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB LkLL <br /> O Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days x-, <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers y' <br /> s. R <br /> Q 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators S <br /> 0 1 0 1 Other: § <br /> Comments 4l lyea G- <br /> Inspection Form Included:Q Od6 / /�' /!��/ `�� �'��y,,� •�- s'C <br /> Comments Included: <br /> Business Rep's SI nature Phone Number'• In'spector's Signature, Phone Number <br /> INSTRUCTIONS ON BACK E ?( A4 M P iL E 12 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0628404.0068 <br />