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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Ste MB18rtomla Survey Form - Page 1 1 4 - 1 0 1 3 350 <br /> cnvMe,e,Maw oao+l Y <br /> CalHomla Intapntetl Wasla Manapemsnt Board <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: O 4 `y L+ 4 L4 ®Routine Q Re-inspection Q Referral Q Observation <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 <br /> Inspected By Inspector <br /> _ <br /> Physical Address Np„.rtq, 3 Cj ' `}G,/ye�"TT�ts <br /> A, - a.# <br /> �tx,(�4•0_ G/�r �sZls Inspection Date d o / <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> �•/ � �5 O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 4/ O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill ell that apply) <br /> - Q Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned !OTR <br /> Business Type (Fig all that apply) <br /> Q 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder ®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 Entitles 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 Fortes 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: § - , f /' A <br /> Comments ! 1 M +� 7� _—Pro,&, s f5 _ <br /> ��>r.1,er ►''1ti..i +- gG.�� /z-l�--04, /�I�,.s�_-3 -_ F"63 <br /> 16-7 <br /> Inspection Form Included:Q p yt <br /> Comments Included: - a 209 <br /> Q Bus egg p'sVre Phone Number Ina or'a Slg ure Phone Number <br /> INSTRUCTIONS ON BACK JEJ rAIMIPILIE1i 2 3 62081 <br /> ■ White Copy:CI W MB Yellow Copy Operator Pink Copy Lam+ ® ■ <br /> 0605204.0537 <br />