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Waste Tire Survey & Inspection Report Inspection Report NumberS tate ■ <br /> = CIWM,Cal(New Survey Form - Page 1 i 9 - 1 Q 3 7 51 <br /> CIWMB teMana04) <br /> California Integrated Waste Management Board <br /> Part A-Survey ___ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 0 0 S - O 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ���yy,, If Referral,choose referral type(Fill one) <br /> Identifier: 1/t/�J l� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facillty Nam::! le Inspected By <br /> m�N Inspector �'(")� 2 <br /> Physical Address - / 0 I �(�� � ( IK' <br /> 1 l ;8� �,l�eJo C� �/ <br /> potc'k ' Cr Inspection Datey / <br /> / O to <br /> Business Rep R0#1 (Sr,pfv, TitleTime In O AM Time Out <br /> O AM <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 /> f ®Active Q Passenger s Generator Q Outdoor <br /> QClosed Q Altered AIA <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q DismantlerQ Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber 9 I <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <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 /> 00 1 Other § <br /> Comments 6�d 6, <br /> D( f .'fie �?f ,�nktr aS_no�'e.d.� /_"--`. <br /> KULt—.e.h—kf s salt OF o w� r` d -to- -was Heol a�►�y: St nesej <br /> -�° �'Lr.� <br /> ` e, V i C;Q E�l V i&I . lU o � a�1-c7rt <br /> 11 <br /> Inspection Form Included: 0 <br /> - p-a g' c ZD'0 <br /> Comments Included:Q <br /> Business R Signature Phone Number I ctor' S gnature Phone Number <br /> INSTRUCTIONS ON BACK X A M - [LIE[ 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® . <br /> 0615104.0480 <br /> t _- <br />