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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State C1WMIf 191(Now <br /> Survey Form - Page 7 i $ - 0 4 l 0 $ <br /> C1WM8 i8i(Naw 04/174) <br /> California Integrated Waste Management Board <br /> Part A-Survey _ _ _ _BLUE_ OR_BLACK INK PEN <br /> rausiness Profile Inspection Details <br /> 7PlD. - -- -� � � � - -- - � — -TInspectiort Type (FIII one) <br /> Site Suffix: - ` I® Routine Q Re-inspection Q Referral Q Observation 1 <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Phy��al dres5 1 �j I - ` d 11, ' <br /> Inspection Date <br /> 5 Time In Time Out <br /> Business Rep Title \,� O AM O AM <br /> 0 PM 0 PM <br /> Operational Status I The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) + (Fill ail that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active j 60 Passenger ® Generator J ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler + Q Indoor <br /> O I Q Inactive Q Truck <br /> Longitude - - Q Planned Q OTR 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 /> iQ Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility r'� r' ( `IWREN, "�-, <br /> 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 y y/; ~✓ ,.� "'" /'�� <br /> Q I O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q I Q 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWM6 j / <br /> Q f 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 <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Qto14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 10j Q Other: <br /> Comments, �Y7S4�?�t✓L � 5 �„�sk--� � L r't-� -1���.��- ��- �_���. � 5 l�"'�' - - <br /> 1 1 <br /> Inspection Form Included: Q P.twrjaS <br /> Comments Included: ,sine Rep's Phone Number Inspec is Signature- Phone Number ' <br /> L 62081 <br /> INSTRUCTIONS ON BACK = „ . >� i' �3 �;; kX t, �ri �P�LI � f , + � <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />