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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Sgratedato of California eMI Survey Form - Page 1 { 3 , 1 0 1 4 31 9 <br /> CIWMB 10t New 04104 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK_ INK PEN <br /> Business Profile I)nspection Details <br /> TPID- � � � _ � � I Inspection Type (Fitt one) <br /> Site Suffix: � 5 0 3 I <br /> I(D Routine Q Re-inspection Q Referral Q Observation <br /> I i <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 9" �o �y� l a i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address D <br /> Inspection Date �K4_SfbGta� C-101 9JJ" d oQ � <br /> i <br /> Time In Time Out <br /> If <br /> Business Rep n Title O AM O AM <br /> Fe4il..e 0 P 0 P <br /> + Operational Status The Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> Tire Count(WholelPTE) <br /> t Q Active Q Passenger Q Generator I Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> Q Q Inactive Q Truck <br /> Longitude – Q End-Use Q Container <br /> Q Planned Q OTR <br /> i <br /> Business Type (Fill 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 6 Other �Q'/��✓ /V'/ o✓ <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility T ITAT-tt8� <br /> x t> <br /> Q Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires nslott- <br /> t�l <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. }+�` ; <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O , 0 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 /> 1f i5r <br /> Q Q 114 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days t• ` � ` <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years xl F <br /> QQ 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 /> O Q 114 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators y# � - <br /> Q Q [Other: § <br /> s-= <br /> Comments A coo(ke fb �an� GO�Qr s�rv'l C e, n'1 a m��•: had <br /> bi Vti,l abs `� rD Y i d-pe a L u55 fD r )ns <br /> Trrc.ic No mani Fes+s r ro vic 4 a# -tiw a tAsped;0;, , -PravrC <br /> Inspection Form Included: QI — YP�T <br /> Comments included: Q – i <br /> 8u Haas Rep's Signature Phone Number In actor's Signature hone Number <br /> � i/_ �� 82081 <br /> INSTRUCTIONS ON BACK <br /> y. E"7( A*P.1LjEjf 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />