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€, Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> St atenr California Survey Form - Page 1 13 - 1 0 1 3 3 3 2 <br /> CIWMe 101(New 04104) <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: I 3 �{ C> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: �j �1 <�O_J7- _ t�H� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ' <br /> Inspected By Inspector <br /> - 1Phy slcai Address 01 <br /> /-�� CS�3� Inspection Date O .� <br /> C./ Time In Time Out <br /> Business Rep Title O AM O AM <br /> ' OwN O PM PM <br /> ( Dinh <br /> Operational.Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) �r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> li 5 ®Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler ®Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q End-Use Q Container <br /> O Planned O OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires u <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle ' <br /> s. <br /> O 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 <br /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years � -�•a -�.. �'; '_s�. <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers i' <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators x ` <br /> O Q Other <br /> Comments l'(Sas.--nn L-J-4 1'61k4 1AV �W-1IG <br /> J)Gv!G.c. � i 4�s1' �r.� '7�Ir-Qi h—a../��• ��1�� <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> B mess Rep's Signature Phone Number I s Signature Phone Number <br /> INSTRUCTIONS O BACK n EaX Al PLEI 1 t 2 3 62081 <br /> ■ While Copy:CIWMB N Yellow Copy:Operator Pink Copy:LEA <br /> 0609004.0024 <br />