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Inspection Report Number <br /> Waste Tire SdRey & Inspection Repor , <br /> CIWstatOM f 81(NeW ) Survey Form - Page 1 i 7 01 4 7 80 <br /> CIWMB181 Newg4l04 <br /> California Integrated Waste Management Board <br /> Part_A- Survey BLUE OR BLACK INK PEN <br /> Business Proflld _ !Inspection Details <br /> TPID- t 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: GjK� J O CHP Q CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name '"�j� Inspected By Inspector <br /> CA,I AV'­V�S <br /> Physical Address <br /> Inspection Date I I <br /> c - R5-zts <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> j r Q PM O PM <br /> �r�r'�:Qe,.�'�-"' <br /> Operational StatusTire 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 f / 0 Active 0 Passenger ® Generator ® Outdoor <br /> 0 O Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> p 0 Inactive 0 Truck <br /> Longitude _ O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer • Auto Repair Q Trucking Fleet o Government O Retreader O Dismantler Q Tire Derived Fuel <br /> JO Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture Q Shredder Q Other f <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility EN ±i ��"� �, I` <br /> H I.�NtlANt)! IFL%T:R=UlREMBNTS : -A <br /> O 'O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Nsrt4rr!► ijfJf3n <br /> o O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> OO <br /> 1 PRC§42956-RegistrationlDecal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> O ' o <br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O <br /> 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 k <br /> o O <br /> 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O , O <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O Q Other: § ,L <br /> Comments r,4- et <br /> r <br /> rv.a�i- rs�-5 a- <br /> 4, 416;6 <br /> 'Inspection Foran Included: <br /> Comments lncluded;Q <br /> Business Rep's Signature Phone Number I pector's Signa are Phone Number <br /> INSTRUCTIONS ON BACK �] X R IJI P L E 1 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />