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HH1H <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> Ie CrwN1f181(Nmia Survey Form - Page 1 I 6 . 1 01 3 31 1 <br /> CI1YMa 181(Naw 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' L,1 - C Inspection Type (Fill one) --- <br /> Site Suffbr: �- ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: h ��� �Ir��h / ��/� O CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name --- <br /> Inspected By Inspector <br /> �r► �o's �d1 ��s 3 - � �� 5 <br /> Physical Address 9 <br /> 2370 <br /> Inspection Date O Z / f / O 6 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> - operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> e ' O Active Q Passenger O Generator Q Outdoor <br /> i0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> O Planned Q OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-RegistrationlDecal 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 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 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 /> 10 1 Q 1 Other. § <br /> Commentsr� <br /> �` rJIw91!r.pfi5r q..F- !25Ar6 <br /> — <br /> nd74 GOy-vill s:t <br /> Inspection Form Included:Q <br /> Comments Included:Q a turre <br /> Business Rap's.Signature` Phone Number Ins 5gngis aiture Phone Number <br /> INSTRUCTIONS ON BACK I E'K A p L 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy LEA ® ■ <br /> 0609004.0331 <br />