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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StWFat'AB1of allfornla Survey Form - Page 1 1 1 - 1 0 1 0 6 6 7 <br /> CIWMB 787 Waste <br /> nage) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- 7 f Y Inspection Type (Fill one) <br /> She Suffix: o I I p� s - 0 1 <br /> ®Routine O Re-inspection 0 Referral O Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: _ O CHP O CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> PD-SDEF Powefr Co►�►-I �1 y��p _ <br /> Physical Address 3 9 O <br /> S�c•�favl G4 �5�b3 - -- - <br /> �� Inspection Date 03 / o") I O 1 <br /> Time In Time Out <br /> Business Rep <br /> Itie Q AM Q AM <br /> 0P QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active O Passenger Q Generator Q Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O ®inactive O Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> j Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder ®Othere(/ -� <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 10 O PRC§42956-Registration/Decal in Vehicle w <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 t^." <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O Other: § <br /> Comments Te f D i-rt� 1 <br /> (�.+ 6 <br /> a"Os <br /> Nr &Ara W WAAadiom /id <br /> oy\ . <br /> Inspection Form Included:Q, ��y/{���.��� /� <br /> Comments Included:O <br /> Business Rep's Signature Phone Number_ I or* <br /> Si atur8 Phone Number _ <br /> INSTRUCTIONS ON BACK A E!X R P L 11[2f3 62081 <br /> '"� <br /> ■ White Copy.CIWMB Yellowflow Copy Operator ` Pink Copy.LEA ■ <br /> 6711604.9173 <br />