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ses <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> araraormi. Survey Form - Page 1 1 2 - 1 01 3 365 <br /> GWMB...iBt(New 04!04) <br /> Caleomla Infearafad Weste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile i Inspection Details <br /> -PID- Inspection Type (Fill one) <br /> Site Suffix: 2 G] © 3 g 5 - Q Routine &Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -�j' (� '5-Hib Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector I <br /> Physical Address <br /> 14152 CA A_ �r <br /> s C w S Inspection Date <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 /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r-> 0 Active ®Passenger i Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q 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 Q Government Q Retreader 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 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other. § ! ,,,�1I L <br /> Comments 5,42-1WtIs /Art fZ_LDE'--k N. /A56r— 1"34A ^�✓�S / , <br /> �'►ti./IrC.4 01 W�� 3So T�"C lA I1►+ <br /> 142 HISS rQ4njI-!" Gv.r_ o,.� �ac(e�t_ /` /a•!'1�s�s/ GTt_s 9.-�_ _ <br /> Inspection Form Included:Q �/Cr <br /> Comments Included:Q l 66 /- <br /> Bu n s Rep's Sign Phone Number I oils ra ure Phone Number <br /> INSTRUCTIONS ON BACK jEjijAjMjP1L1Ej1 Z 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0609004.0332 <br />