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Waste Tire Survey & Inspection Report Inspection Report NumberState. ■ <br /> CIWMB <br /> Survey Form - Page 1 1 4-- 1 013490 <br /> C8NM8 181(New 04/84) <br /> Califomfa 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 9 p 3 b � ( Routine QRe-inspection QReferral <br /> Q Observation <br /> Local (D If Referral,choose referral type(Fill one) <br /> Identifier: J Q11Z �Q � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected ByInspe,�fo <br /> 1/a.i G3��. ; ? - / o ( S' �4)i <br /> Physical Address �,0;A/''AD'A <br /> /(6$'� �'• �t4 res <br /> Inspection Date D 0 / � Q 6 <br /> Time In Time Out <br /> Business Rep Title0 AM Q 0 AM <br /> 6.14 -) V-11 Q dk!/!a(.T O s- 0 PM D I / O PM <br /> /`�� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ° (/ 0 Active Q Passenger 0 Generator 41 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q 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 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 •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 /> Q Q Other: § <br /> Comments �^ e •'P d G�►ua® ��y ua,+4� <br /> — — <br /> u""'r / 4a'.e ./Dar "'4:-t <br /> �udds <br /> lAl t f �K .�a.c�e T� 3 4 � 44,a, t X, Qu <br /> Inspection Form Included:Q <br /> Comments <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK IFIXIAIMIPILIE1 111213162081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0617904.0099 <br />