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Waste Inspection Report Number Tire i . ey & Inspection Re o% <br /> State of California <br /> CIWMB tBf(NewQ4104) Survey Form - Page 1 17 - 1 D Z 5 86 9 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �,/j 3 �^ ' Q Routine Re-inspection Q Referral Q Observation <br /> Local / }� If Referral,choose referral type(Fill one) <br /> Identifier: �h �,,,-�`/.�'`�t,�� ��� IQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Y <br /> Ph sical Address <br /> Inspection Date � � I •� ? <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ' t O PM O PM <br /> I <br /> f Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fil(all that apply) (Fill all that apply) : (Fill all that apply), <br /> � � l <br /> *Active Q Passenger ® Generator Q Outdoor <br /> 0 I i <br /> Q Closed Q Altered <br /> GPS Latitude - I i Q Hauler Q Indoor <br /> 0 Q Inactive 40 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 *- rucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Deafer 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 ggfgRCEMENTSTATUS <br /> f V' A' HAULINQ ANO.MANIFEST ROQU)REMENTs l <br /> Q Q Q Notice Of Vb►ption Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Camphene Doadline <br /> PRC§42956-RegistrationlDecai in Vehicle <br /> Q Q i 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Qate. m I m <br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 114 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 01 O f 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers enforce <br /> Jment <br /> Q Q 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators10 �� <br /> QOther: § <br /> Comments ��y h�%t5 s�tv 't"' h0.r.0 t../at�G- �l t^�,� L°�-►•...c`7� � il��-�—���� -Fr">� j�S( i..�l-�.� -�r 1� �l YT:�i Y`�'�^�v� � •Vim— <br /> Ilnspectlon Form Included: Q <br /> Comments included: Q <br /> Business gnature Phone Number In or's gn ure Phone Number <br /> INSTRUCTIONS ON BACK �CarlaO <br /> ft y(t�t3t'I` s: �[ wY._ .M�P1 62081 <br /> White Copy:CIWMB Yellow Copy;Operator Pink Copy:I-EA <br />