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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> $tatBforma Survey Form - Page 1 1 8 . 1 0 0 6 3 7 4 <br /> C1W 181(Ne 041 4) <br /> Calilomia Integratetoe181 d WasManagement board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details. _ <br /> TPID- Inspection Type (Fill one) <br /> Site Sufib L y 0 Routine Q Re-inspection 0 Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: �O i+�tt� +� Q CHP 0 CIWMB 0 Complaint 0 Educational Visit Q Other <br /> Business or Facility Name -- <br /> �C� Inspected By n Inspector <br /> Physical Address <br /> /9 Sew /!/. xlieu,� - <br /> �,��� Inspection Dale / 0 o / 0 ,/ <br /> Time In Time Out <br /> Business Rep Title/O 0 AM / 9 AM <br /> 17112 A44ea�i/ / / / 9 0 PM ! / 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 20 <br /> Q <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t t I <br /> 0 Active 0 Passenger 0 Generator •Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0Hauler Indoor <br /> O Q Inactive 0 Truck <br /> Longitude – 0 Planned Q OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair *Trucking Fleet 0 Govemment 0 Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection 0 Crumb Rubber <br /> Q Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B Inspection of Waste Tire Dealer Generator,Hauler and End Use Facility s <br /> .A- ....`. <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts With Registered Waste Tire Haulers. �" z <br /> Q Q PRC§42956-Registration/Decal in Vehicle >.„« •��.;+, <br /> 0 0 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements _ <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIW MS <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q•0 14 CCR§18460'.2-Manifest System Requirements for Registered Waste Tire Haulers y` <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators "`M - <br /> 0 0 Other: § <br /> Comments .zct /!'diy�Z7r9 ',.f/ �� �orG✓ 9 �6r// Lc_%/a� Ltl/y/F+�- <br /> Qc°.��-�s _�� f/l�r-��f�-f K✓Qc� I/�•C � �$tte.(�i�-cs Lt `�+�".*1 <br /> 7'P' . 3� Gc ftp//c[/ccyyC� Y�i yy— <br /> Inspection Form Included:Q / <br /> Comments Included:Q <br /> Bu s S at Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK R A M P:L E1 111213 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br /> 0630504.0037 <br />