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4=Q Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> state of California <br /> CIWMB i8ast1eMarage, Survey-Form - Page 1 _ 1 6 - 1 Q G 6 4 9 6 <br /> - California Integrated Waste Management Board <br /> Part __ BLUE OR.BLACK INK PEN <br /> Suslness:Profile, inspection Details <br /> TPID- p 1 Inspection Type (Fill one) <br /> Site Suffix: v 5 .Z - \ Routine 0 Re-Inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 15 5-0 <br /> Inspection Date Q / p <br /> 9�ao3 <br /> Time In Time Out <br /> Business <br /> ``Rep <br /> � Title / *AM 0 AM <br /> cy`1T \����/ Sv c✓�v.�Jl� O PM O PM <br /> J 1 - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) a „1 (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> C/ •Active 9 Passenger •Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude � 0 Hauler 0 Indoor <br /> O 64nactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) • <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 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 /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> PartB-.Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. r r <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements as <br /> K ; <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § \ \ <br /> Comments f� <br /> / �1\ <br /> ,ria�r �,s �h4._u� le c..,9._-�;�..` �ti..d�. _��\� ,��.�•�'«�.f� <br /> Entered <br /> Inspection Form Included:0. <br /> Comments Included: —-�"r- -u�(1 �7 SS 76> <br /> using 's Signature Phone Number InspectyrP�-�: Phone Number <br /> �„ - - -- 62081 <br /> S ON B -- <br /> INSTRUCTION EIX AMP � 1 .2 3 <br /> ■ Fa.-'< .t a��.re=xurwmaKw. ia«. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0529204. 1188 <br />