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«Qa Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CIWM Kalifornia Survey Form - Page 1 1 5 . 1 0 1 0 7 3 7 <br /> CIWMB 181(New nage <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID ' ' — O I Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ��,, If Referral,choose referral type(Fill one) <br /> Identifier: SQ(�, Jj a ���' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ( W- Redly S17 - 1ru� <br /> �- <br /> Physical Address l : o / etif,�(„ <br /> AiS Lc)oAAA'-S d , ^ <br /> GA95��C Inspection Date <br /> J i Time In Time Out 111 <br /> Business R(�e�p�n �Ny TitlerO AM Q AM <br /> Operational Status The Type Business Role Storage Type <br /> Fill one only) (FIN all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ! b I <br /> t Q Passenger ®Generator Q Outdoor <br /> U Q Closed Q Altered <br /> GPS Latitude Q Hauler I, Q Indoor <br /> O ®Inactive ®Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tlre Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 41M_ VAN <br /> S <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 v <br /> Q Q 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 /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 14 CCR 18459.3-Retention of Manifest Forms and Tire Tri Logs for 3 ears <br /> Q Q § P 9 Y <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 , ` t <br /> Q Q <br /> 14 CCR§18462-Manifest System Requirements for The Dealers or Waste Tire Generators <br /> Q Q 1 Other: § <br /> Comments .�fl +� T('li s I e <br /> `u� wt l - c+ sWc�s`� -f(res -f o t j nr�ill/ <br /> Ol r Oh szfe I eStAJ1 9, <br /> Inspection Form Included:Q <br /> Comments Included: <br /> B slness Rep's SI ature Phone N er In or's S g ure Phone Number <br /> INSTRUCTIONS ON BACK R Ti9 p 62081 <br /> ■ 0716504.0004 White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />