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" '■ eggWaste Tire Survey & Inspection Report Inspection Report Number- ■ <br /> . <br /> State <br /> e <br /> ClWM 181(New <br /> Survey Form Page 1 - - l 4�- 1 01 3 9 <br /> CIWMB 781(New nage <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business-Profile:. Inspection Details <br /> TPID- /'� �� ) Inspection Type (Fill one) <br /> Site Suffix: V 1 7 ® v ! Q,Routine Re-inspection Q Referral Q Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Educational Visit Q Other&,Vt <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Adpress 1 cis 30, <br /> A <br /> 109, EAl --- - - - - <br /> �� Inspection Date <br /> CA <br /> Time In Time Out <br /> Business <br /> Rep Tittle/ 0 AM 0 AM <br /> O PM O PM <br /> - 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 /> Q Active ® Passenger ®Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive I&Truck <br /> Longitude — Q Planned Q OTR ®End-Use 9 Container <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 0 Other 5� <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 0. PRC§42956-Registration/Decal in Vehicle t <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements x <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 N <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years fk ° <br /> Q Q 14 CCR§ 18460,2-Manifest System Requirements for Registered Waste Tire Haulers <br /> .a <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 /> 01.0 Other: § ,y/ <br /> Comments_ �fe . 1 k fm How im Was !`icfed &nr►of `)j -e <br /> IV 10 S-1rPS -Aims 0-+ -AZs varCk . one qp i{" kin I,)RS <br /> JOS+ `tir>°S �v �e AalAAed C fSC�'Ci:r (�s All <br /> OC 09 1 <br /> Inspection Form Included:Q <br /> Comments Included: Q -1- "l 6 <br /> ess ep's ure Phone Number s ctor's ig ature: Phone Number. <br /> 62081 <br /> INSTRUCTIONS ON BACK A M P E i 1 !- 3 <br /> ■ � ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0622804. 0430 <br />