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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> C1WMB 197(Naw 04104) Survey Form - Page 1 1 8 - 10 1 3 6 4 3 <br /> CNYM <br /> castor-iaIntegre led Waste ManagennentBoard <br /> art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ^ Inspection Type (Fill one) <br /> Site Suffix: y 3 S g o N ' 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ` B Referral,choose referral tYPC(Fill one) <br /> Identifier: � C/t?4 ji1ti N Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name O Inspected By Inspect9r� <br /> ply �3. ��c�c.Ca� . iLG , YJl,A <br /> Physical Address <br /> Inspection Date D 6 Q <br /> (� O Time In Time Out <br /> Business Rep Title !AM 0 AM <br /> ��� �l1'�-/ �•tjj��t.('r 0 9 : � / QPM ! D `. ( 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ) L (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / D 9 Active Q Passenger ®Generator 0 Outdoor <br /> 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 •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 /> Q Q 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 <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: § <br /> Comments �Qer Vii_ CGjGf f'�TQltfcVr9 r�/f"C � �C LC/4�^E�t <br /> s <br /> � <br /> Inspection Forrn Included:Q <br /> Comments Included:Q Business R s Sig ature lg Phone Nu /bar Inspector's SignaturePhone Number •�S <br /> INSTRUCTIONS ON BACK I EIXIAIMI P IL I EI 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® . <br /> 0622104.0026 <br /> r <br />