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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> $ California Survey Form - Page 1 1 1 . 1 0 1 3 6 8 6 <br /> CWIWMR MB 191(Now 04/04) Y <br /> California Integrated Waste Management Board <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- S Inspection Type (Fill one) <br /> Site Suffix: 3 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local (� If Referral,choose referral type(Fill one) <br /> Identifier: 4+L Q CHP QCIWMB QCom Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address <br /> /9767- /rl/ G ``e,Ef 46'-e - <br /> Inspection Date 0 ! / '1 2- / Q <br /> v <br /> Time In Time Out <br /> Business Rep Title / 3 : 9 �'AM ( . ` . AM <br /> -D4 /C c�f (� /O�rT Q / 0 PM `� PM <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(VVholelPTE) 1 I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ' / &Active 0 Passenger 9 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive I*Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 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 P <br /> Ml <br /> Q .Q PRC§ -42951 Waste Tire Hauler Registration and Transport of Tires <br /> :_ ��•.-S�` '��'F,1 ai'a�`�"k'a $�,kyLw,r;�5 .�•• S+a�: <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q 0, 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 o <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 /> I <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: § f , <br /> Comments /"6 "°�7� r{c f�PJ►S(10es 9r�e+'�Gf�� e2KCY /,//�.y, t!/ icJ14v�,� <br /> s. <br /> Inspection Form Included:Q <br /> Comments Included:Q t �L� J y��' <br /> BInes Reps Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK IE 1XIAIMIplLIEI I1(2131 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> R 6_11 r C14.11 Nyr <br /> r <br />