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t= , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State California Survey Form Page 1 1 9 1 0 0 6 6 9 8 <br /> cIWMaed 18Wa1(New 04104) <br /> CallrCa'...Integratete Management Board <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> �Site Suffix: ` �y *Routine Q Re-inspection Q Referral Q Observation <br /> Local �'- If Referral,choose referral type(Fill one) <br /> Identifier: �pA � �-.T Gf,` <br /> 1� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> -- -- �� - -- -- <br /> Business or Facility Name - — -- - - <br /> Inspected By Inspector <br /> Physical Address L 1 } <br /> —2-5;o 57C-:- <br /> Inspection Date O Z <br /> 952 S <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ®Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer §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 ° <br /> ij <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires - t <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 /> t <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 Q Other: § .,.,. <br /> Comments iSCll��� Di:� �iS � Kls- w # T-'rYF Tr7Jw 2111$ <br /> 00 4v <br /> Inspection Form Included:Q Y <br /> �$z9 <br /> Comments Included:Q - - - - --- - <br /> Business Signaturea. Ph umber Inspe or's Signature Phone Number <br /> I+ t <br /> INSTRUCTIONS ON BACK � �1+,I PI 10XIAIMIP[LIE1 11[2131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA �� ■ <br /> 0716204.6208 <br /> ■ <br />