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Waste Tire Survey & Inspection Report p p <br /> Inspection Report Number <br /> State of <br /> C1WM Survey Form - Page 1 1 3 - 1 0 1 3 1 3 5 <br /> CIWMa 181(New 041041 <br /> Calffomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- J n O / Inspection Type (Fill one) <br /> Site Suffix: f �y /7 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �7 If Referral,choose referral type(Pili one) <br /> Identifier: �'t- � II Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Rte`. <br /> Business or Facility Name Inspected By Inspector <br /> �,-Aye <br /> Physical Address �� <br /> 1217 - <br /> Inspection Date <br /> �p Time In Time Out <br /> Business Rep Title/// Q AM AM <br /> /� ! �t..'�- /rTC�•r�Q (/`�as'r / • © 9 8 PM 2 �pZ �PM <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 /> r r 0 Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O i Q Inactive Q Truck <br /> Longitude - — Q Planned Q OTR I Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 Q 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 Of V{Watigd 0 Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. otttPilaL sat�tine <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements 17aie , <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB x <br /> u� <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 daysil9t <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years e c <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q R,8fs61l* , Ettfarirexktert <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 Generatorsi n ,_ <br /> Q Q Other. § 1 � <br /> Comments r'2e�'i �/�" HQr/ �C O/ � 77�,y s <br /> 41,,le a lam,'fid f�t� /ate k .; , f - .✓. �o <br /> Inspection Form Included:O � <br /> Comments Included: <br /> sines Rep's lure Phone Number Inspector's Signature Phone Number <br /> . INSTRUCTIONS ON BACK ® X A P L'E 1112131 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br /> 0r.7�4 i R4,0273 <br />