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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of <br /> CIWM Survey Form - Page 1 I - 1 0 2 5 7 9 <br /> CIWMBi81(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey -BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- l Inspection Type (Fill one) <br /> Site Suffix: i 36:7 r - l Q Routine 10 Re-inspection Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: Nf� � C_/ib Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �" f P Y P Ins ectad B Inspector <br /> f� <br /> Physimess J <br /> 3 <br /> �'t-f-� � �it per- (,•�a <br /> r Inspection Date C) 2 0 f 0 -5 <br /> Time In Time Out <br /> Business Rep �./Title (�AM O AM <br /> /Q .05a,4 1,11,0�" QPM 0 PM <br /> 31111 Operational Status The Type • Business Rola Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger •Generator I0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Hauler Indoor <br /> O Q Inactive Truck <br /> Longitude Q Planned Q OTR End-Use ®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 ®Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility k E J 7j:ITATUS <br /> E _ v <br /> . At 1'InIt1At4�+1`. lT R 'i1CItC�QNTli. . F... . x ; <br /> Q OQ: Iola on Q Extendo� <br /> •PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> OO 'PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB ;` 1 <br /> Q O <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> r , <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years i <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers lt ► Ift <br /> O O <br /> 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 /> O O Other: <br /> CommentsInle, _.05. paw-G� ! , CA - <br /> l <br /> t - 'Z-7Z 5 iv('� ., Ha IA/QC- VAS A�11 C.O W 40 4011 <br /> Inspection Form Included: Q <br /> Comments Included:Q - <br /> Business IR p' ignaturs hone Number Ins r s Sig t Phone Number <br /> —SPA <br /> INSTR �b4ed ON BACK <br /> [ ✓ . �/� ��1 n_.:f .. f" �L �I' I P �� 2 3 62081 <br /> !G <br /> KS <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />