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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StWMBate 81(Nnla Survey Form - Page 1 1 1 - 1 0 6 3 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection! - Q Inspection Type (Fill one) <br /> Site Suffix: J( 6 Routine Q Re-inspection Q Referral Q Observation <br /> Local 7 If Referral,choose referral type(Fill one) <br /> Identifier: SGtpL �QQt,yo`j L�[u — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> TS LOtcij�ce�lC. /,f'� 3 /%r�14i9 <br /> Physical Address <br /> Z 60g SfQQT_veze ,�' - -- -- <br /> Inspection Date D 7 / 2 . / d <br /> Time In Time Out <br /> Business Rep Title g t; •AM <br /> / O PM v I 0 PM <br /> L Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Jr n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V <br /> *Active �Passen Passenger <br /> 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive i Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 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 a <br /> Q Q PRC§42951 Waste TireHaulerRegistration and Transport of Tires ay t <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> m <br /> Q Q PRC§42956-Registration/Decal in Vehicle : <br /> Q O 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 <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days 3 *. <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities :' �. n ,t <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments //7L' <br /> �-� 2.k p A ae- ),rye i 'moi, %�% 0 <br /> "H�»�u-►��! auea! Gni^�c �/ay�'o� Seip <br /> Inspection Form Included:Q "1�� a�./� O Q <br /> Comments Included:Q <br /> Business Rep' Signature Phone Number Inspector's Signature- Phone Number <br /> ■ INSTRUCTIONS ON BACK P 11-10 3 62081 <br /> Nhite Copy:CIWMB Yellow Copy;Operator Pink Copy:LEA ■ <br /> 0622604.0426 <br /> FILL COPY <br />