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== Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> of <br /> r State of California <br /> CIWMBt81 aste(NewManage04104) 6 96 <br /> Californiaurvey Form - Page 1 1 3 - 1 01 3 California Integreted Wment Board <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: f 3 9 3 6 o 0 Routine Q Re-inspection Q Referral Q Observation <br /> i <br /> Local _ C 9 If Referral,choose referral <br /> Identifier: type(Fill one) <br /> �- � *��t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspecto <br /> Physical Address 7 LLf3/�DiA//��✓� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title n J- i AM / Lj �7 ®AM <br /> O PM ( / ( ( O PM <br /> - Operational Status Tire Type Business Rote Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger !Generator Q Outdoor <br /> d <br /> O Q Closed Q Altered GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude _ Q Planned 0 OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair •Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel l <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> LQ 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 /> E <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. - •'N s, <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> N. <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 /> 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 4!G ' <br /> ft-a� lL& rp L11vf is e�AteL /O/c if ff ami f/L GL eo/a 7ze Zts2 9 u �� <br /> qua")4 (6120 9k� 4,LW. 3a4_• <br /> Inspection Form Included:Q . <br /> Comments Included:Q g <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> <'g ,�sry^,xA <br /> ■ INSTRUCTIONS ON BACKMi - )f I A IMI p C 3 62081 . <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0633364.0078 <br />