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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CIWM f 1111(Now Survey Form - Page 1 19 - 1 01 4 7 5 8 <br /> CIWMB 1t11(New 04((14) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1Inspection Type (Fill one) <br /> Site Suffix: 3 7 -7 <br /> C� f ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: `�^ �f„-_ r4y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name / <br /> Inspected By Inspector <br /> L-410.5 <br /> Physical Address C> (0" - ,, L•,-s, <br /> Inspection Date 1 � I 09 <br /> 'try— CA`t l / <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> V^ I QPM QPM <br /> J Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f f 49 Active • Passenger Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR O End-Use Container <br /> Business Type (Fill all that apply) <br /> '46 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel f <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFOJZCMBNT ' ATI = <br /> V 'A HA�U .NG AND MAM) EBT REQUIREMENTS - <br /> tttttll <br /> O Nath Qf �l9b <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires VlQlailon (� <br /> 0I PRC§42953-Contracts with Registered Waste Tire Haulers. Compllalttt< l�+ll�a <br /> 0 0 PRC§42956-Regis trationlDecai in Vehicle <br /> 0 ; 0 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 C) 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CfWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requkli:d fi >�►?llq►"EX� <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers (�R!(`etrOd/ ��IIIJNIEfff1}ff�til1 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> K. <br /> Other: § <br /> Comments <br /> 1 S �,� �^C�t 5-�.��Q t,✓a y�G -'�!✓� `�i�.1 a✓ C r✓1 7'' 1$(G <br /> rip <br /> Inspection Form Included: <br /> Comments Included:0 Zy 8'rb <br /> Business Rep's Signature Phone Numb`er� or's ign ure Phone Number <br /> INSTRUCTIONS ON BACK [-Corroctl�.-W611*gat_ M I E A �h P ES 2 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />