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E Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 8tate ofgrated California <br /> Survey Form - Page 1 1 8 1 01 31 8 0 <br /> CIWMB 181(Naw 04104) <br /> Caliromla Integrated Waste Management Board <br /> part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / � _ ('i / Inspection Type (Fill one) <br /> Site Suffix: •Routine Q Re-inspection Q Referral Q Observation <br /> Local 5) If Referral,choose referral type(Fill one) <br /> Identifier: SGyc 1-42 Zr G <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — -- <br /> Inspected By Inspector <br /> Physical Address <br /> � ; Inspection Date <br /> 03 <br /> / 01 07 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> y�� � /� OPM OPM <br /> /'ys (�/nLe,� 0.;41 Ler <br /> Operational Statin 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 /> 0 Active 0 Passenger 0 Generator ®Outdoor <br /> OQ Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive Q Truck <br /> Longitude - Q Planned 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 /> LOService <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <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 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§18459.2.1-Submittal of Manifest Forms 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 ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § - <br /> Comments <br /> /G1Jc.tft+?•r4' r l;/�1tr/�ISJ z ��"+J' �f<z.yG�J�-✓�c <br /> /"r' c, /1 <br /> C�2ieta'-=7lvL� � ��� //%'� LL/�u/,.�'��y+'`r / rr'�� 'S f�u� cz��.r'r`e�f=t:'� ,�•� <br /> Inspection Form Included:Q 1-1 <br /> Comments Included:Q 13—us,n- <br /> ess Rep's Signature Phone Number Inspector's Signature !� Phone Number <br /> ■ INSTRUCTIONS ON BACKl;IElxJAIMIPILIE[ ii{ I I 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA P . <br /> 0710204.0210 <br />