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Ear Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of 181(New <br /> Survey Form Page 1 13 1 Q 106 7 7 <br /> CIWMB 181(New nage <br /> Califomla 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: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: V Q CHP Q CIWMB <br /> al Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> ,Sa.2va. <br /> Inspected By Inspector <br /> Physical Address 3 <br /> W� CA L?!go 3( Inspection Date L� / O <br /> � <br /> Time In Time Out <br /> Business_Rep <br /> � `� Title 0 AM Q AM <br /> UX V ()r 1C1 5 Q✓IJrW( 0 PM QPM <br /> Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count(Whole/PTE) �7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger ®Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> 0 Q inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q 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 /> O 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 /> I <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <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 <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments <br /> _^ �►1�C�Z�r►�.s G«e � aS tec�� `flus ��� <br /> hau.Q S q t qs jour`K _o �er rt 1 gwaj <br /> 'r � irn�M f►�,�ec�ie,i I�pOrf on $t t v�/awF Vial ohs Yer�acf,4 <br /> Inspection Form Included:Q p�� <br /> Comments Included' 2fo 1 S _ D <br /> sr ss Rep's Signa ure Phone Number_ In c is nature_ Phone Number <br /> INSTRUCTIONS ON BACK X a P ' 62081 <br /> ■ 0716504.00:23 White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />