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m <br />e� Waste Tire Survey & Inspection Report Inspection. Report Number � <br />_ Irr1; State of California <br />Cgrated ,stleManage, Survey Form - Page 1• -1 6-100670 <br />. . .3 <br />California Integrated Waste Management Board <br />Part A - Survey _ BLUE OR BLACK INK PEN <br />_ <br />Business<Profile Inspection Details <br />TPID - Inspection Type (Fill one) <br />Site Suffix: y �. - ' <br />® Routine Q Re -Inspection Q Referral; Q Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: S aH p ck 4 V\ C""' - } Q CHP Q CIWMB Q Complaint Q Educational Visit 'Q Other - <br />f <br />Business or Facility Name �" — <br />Inspected By Inspector' <br />I <br />Physical �d e 1 Ti t ��O r` 6rcra,4,11I. ' <br />l 1 Inspection Date / 7 T / S <br />Time In Time Out <br />Business Rep -,-:Title//�� ® AM IS AM <br />C)'1 v , <br />O PM ` o O PM <br />Operational Status I Tire Type Business Role.. ' Storage Type <br />Tire Count (Whole/PTE) L (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />v <br />, , <br />v ® Active ® Passenger e Generator ® Outdoor <br />O Q Closed Q Altered <br />GPS Latitude Q Hauler Q Indoor <br />O Q Inactive Q Truck <br />Longitude - Planned OTR -Use Container -- <br />Business Type (Fill all that apply) <br />® 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 Q Other <br />Part B Inspection of Waste Tire Dealer Generator Hauler and End -Use Facility <br />CV.-�. ,1_,.�T'. x"rimmlli7._{r'-.,t`�?"�TP�`. <br />.s^A.,r'�'�+z t. <br />Q O PRC § 42951 Waste Tire Hauler Registration and Transport of Tires ,r <br />• <br />'. <br />Y .. , .fir•. �:-' <br />Q Q PRC § 42953 -Contracts with Registered Waste Tire Haulers. F <br />Q Q PRC § 42956 - Registration/Decal in Vehicle'` <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 k- <br />O Q 14 CCR § 18459.2.1 - Submittal of Manifest Formsand Tire Trip Logs within 90 days ,. <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years ' <br />14 CCR § 18460.2 -Manifest System Requirements for Registered Waste Tire Haulers Y ,�y�;�• <br />Q Q 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities oy '', ''' -• <br />Q Q 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators t - <br />Q 1 Q Other:§ <br />Comments <br />anjerw <br />KR <br />Inspection Form Included: Q ,1AtJ�1yuL <br />Comments Included: Q <br />BuslnessR p's Slgnature,•. _ • Phone. Number Inspector's. Signature Phone Number <br />INSTRUCTIONS ON BACK E"xi1I11, 1t+ P 1 62081 <br />White Copy. CIWMB Yellow Copy: Operator Pink Copy: LEA <br />0529204.1062 <br />