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Waste Tire Sw :y & Inspection Report nspection Report Number <br /> at <br /> Sate Bof California C 04104) <br /> Il - 1140841 <br /> californialne grat d'81 WaseeManagementBoard Survey Form - Page 1 <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: { C 0 / 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: c\ [i`1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> � v <br /> Business or Facility Name - - -- --- - <br /> Inspected By Inspector <br /> Physical Addres (/ �L f lL�y L4 �e� <br /> o <br /> C Inspection Date <br /> CJ i�C9�irL f UYV � �S a�o� <br /> Time In Time Out <br /> Business Rep Title / f ®AMj _ • AM <br /> © 3 QPM / f S 0 P <br /> fin �-v;`nL olt�c2 l -- - - - <br /> --- - - -- t�=�'"` �' Operational Status Tire Type Business Role 9 yP <br /> Stora e T e <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active I* Passenger i I®Generator 0 Outdoor <br /> -- - D 0 Closed ®Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude - 0 Planned •OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet ® Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> I <br /> 0 Service Station Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> A HAULING AND MANIFEST REQUIRMENT <br /> mAN , r �. . .a ,a4 <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires < <br /> 0 0 :PRC§42953-Contracts with Registered Waste Tire Haulers. ' <br /> 0 0 PRC§42956-Registration/Decal in Vehicle ' t' <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements ' <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> i <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other. § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: - - - -�������`� <br /> Business Rep's Signature Phone Number -r,-,pector's Signature - Phone Number <br /> - -- - -- <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct 11' dire"'t, X A L t g 2 3 <br /> . VT I C <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y:L A <br />