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Waste Tire Survey.& Inspection Report Inspection Report Number <br /> r and.dc.af_k <br /> tatter-^ I Survey Form - Page 1 1 4-- 10 13 6 5 6 <br /> c.abm■kdgdM w..a wn.a.re.d ao.m <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile-- - - inspection Details <br /> TPID• / - / Inspection Type(Fill ane) -- <br /> Sitffi <br /> e Sux: O *Routine Q Re-inspection Q Referral <br /> Q Observation <br /> Localn` / N Referral.choose referral type(FIN one) <br /> Identifier. ✓Q/L _/wfll y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Omer <br /> Business <br /> 'oroFacility Name <br /> C- a Inspected By Inspect <br /> Physical Address 3 9 - / 0 / <br /> /e2 33 yvJG!/ aff�v Ulay -7 <br /> /J -- <br /> C,4 ?,5- Inspection Data 0 / <br /> Time In Time Out <br /> Business Rep Title D e /e AM <br /> /r <br /> ��jj Q PM <br /> ////_�55 / <br /> LAh JM.t A- �1 PLLiTl O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) S (Fll one only) (Fa all that apptyi (Fill all that apply) (Fm all that apply) <br /> 0 Active 0 Passenger f Generator 0 Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> O <br /> Q Inactive .Truck Q Hauler Q Indoor <br /> Longitude _ Q Planned Q OTR Q End-Use 0 Container <br /> Business Type (Fir an that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismen8er Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Comb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Omerp/��G p � ��• <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q 1 Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulms. <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§16459.1(a)(b)(c)-Tie Program ID Number from CIWMB <br /> Q Q 14 CCR§16459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Fortes and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§164602-Manifest System Requirements for Registered Waste Titre Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Two End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 1010 Other: § <br /> Comments fa+tc"P dost a,�.d ..Clow.�yo w4j �co,4+�✓: <br /> tae,P %-R T y!o /c curve �v y�lia� E %'s Vi wtc� <br /> a., e aC <br /> ii4e a i�C�xeac�n. p /l/ WA -1'St,-q <br /> Inspection Form Included:Q 1 r—� ,, <�K6-�f`ocl •e �le.�D33 <br /> Comments Included:Q <br /> Com <br /> Business Rep' Signature Phone Number Inspector's Signature _ Phone Number <br /> ■ INSTRUCTIONS ON BACK ®® E X R�Ih P L E 1 2 3 62081 <br /> Whhe Copy-CIWMB Ydoe C.W.Operator Pink Copy.LEA ® ■ <br /> 0622804.0429 <br /> 0631904.0035 <br />