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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CrWMeferiNewDual Survey Form - Page 1 1 4 �- 10 13 4 0 0 <br /> cnvMaw <br /> California Integrated Waste Management Board <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 O 4 1 q Z l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0^1 �' N� ^�� �ND Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name o'� (JQt <br /> � Inspected By Inspector <br /> Physical Addre 2 G' ( � S <br /> 2 �� GA Inspection Date Q J 2 / O 6 / C <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> I 150 (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply), <br /> Tire Count(Whole/PTE) <br /> Active Passenger •Generator ®Outdoor <br /> O , Q Closed Q Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR I Q 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 <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> k.. <br /> i <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: §/�pp L r <br /> Comments <br /> C,l <br /> -C- <br /> Inspection <br /> l 1P--� (/Y_.lJ l 2L✓[�� _-_ —_ <br /> e <br /> Inspection Form Included:Q �' Phone <br /> pry D ���olJ <br /> Comments Included: I •��Jf- - alp <br /> Business RNumber In cto's a r Phone Number <br /> 0II r !til A P 62081 <br /> INSTRUCTIONS ON BACK I II I �I � ����� C5i�1 � �E��� ��� ���E�� �I IS ILII fl�IJI�� V� 9 � I I <br /> 23 <br /> White Copy:ClWIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0609004.0049 <br />