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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate of Callfornla Survey Form Page 1 1 4 1 0 0 8 0 2 0 <br /> CIWMB 101(New 04!04) r <br /> California Integrated Wast.ManaOement Board <br /> Part A- Survey BLUE OR BLACK_ INK PEN <br /> Business_ Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 7 �rj Q Routine s Re-inspection Q Referral Q Observation <br /> Local v If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> l-al u'Ss S� 2,'�.s .3 9 <br /> Physical Address <br /> Inspection Date <br /> Sz�S <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> �y I O PM O 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 /> 1 1 <br /> ,OC <br /> Active Passenger Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude – Q Planned 1 Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 ENPOR0 , <br /> HAVLI.NQi,--AW-MA$lft&T R&4LNRi MENTs ,mss <br /> �tl ; <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires "M7��w,1 <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> O § 9 <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 014 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs.for 3 years <br /> O 1 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O 1 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities :--:;!,r•4.��.:�. -�- �' %%jam <br /> O I O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § <br /> Comments 1�1 tr ©+^.'�' v"`�n 1.�✓'r3 lrl(^� 1 T t � � ���T d6�� `_� <br /> -F- <br /> � <br /> Inspection Form Included: t0 _ <br /> Comments Included: Q!__C 0 0r — /1t�( <br /> 1 Business Reps Signature Phone Number I actor's Signature Phone Number <br /> INSTRUCTIONS ON BACK 0sleI <br /> }( /Iy p y 2' 3 62081 <br /> _ •S- <br /> ■ White Co T:CIW .Yellow Copy:Operator Pink Copy:LEA <br />