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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> Cgrated 1st(New Manage) Survey Form - Page 1 l 1 0 1 4 8 5 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile _ — I Inspection Details -- <br /> TPID- Inspection Type (Fill one) <br /> Site Sufflx: f 0 6 -7 j - - C> 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � �Y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ! i Inspected By Inspector <br /> Physical Addr s 3 9 - l © �� t 9 <br /> Inspection Date C) I , 4t <br /> C 7 I p s <br /> cx-�--tiara. c�J 2X.2_1 1t <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> / p O PM - OPM <br /> Operational Status! Tire Type 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 /> d� f � � � ,� <br /> Active 0 Passenger 0 Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude + Q Hauler Q 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 /> 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 f ENFORC_ M T STAT„ <br /> V A HAULING AND MANIFEST REQUIREMENTS .r j <br /> Q Notlot►;Of <br /> ylaltlon � <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compllitttge 174id{kte iris, <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data <br /> O O 14 CCR§18459.1 a b c Tire Program ID Number from CIWMB <br /> LL_��JJ LTJ , <br /> (Requlittw'farNi�l� �� <br /> Q O ,14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 114 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q EIef Its�t D1 <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities %:�..a•' <br /> O O � � `'. - %rte f'•3;�; <br /> 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r { <br /> O O Other: § xh <br /> Comments <br /> 1 A_j r, - 0i+- CC->'f9'7) - ���1 �- tl oo 33 r Li­- oot v&4i/ i s <br /> Inspection Form Included: Q ? o ��y/� <br /> Comments Include -- -- — — — - % � �-D� . <br /> siness ep's Signature Phone Number Ins ors Signature Phone Number <br /> INSTRUCTIONS N BACK lcorrect incorrect' E X A p 4 f 62081 <br /> `� �oS . <br /> White Copy:CIWMB Yellow Copy: (Operator Pink Copy:LEA <br /> 1 <br />