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• 0 <br /> i o Waste Tire Survey & Inspection Report Inspection Report Number . <br /> State of California <br /> CIWMB187( egSurvey Form - Page 1 1 9 - 1 0 2 6 6 9 7 <br /> California Integrated Waste Management <br /> Managee ment Board <br /> Part A-Survey__ BLUE OR BLACK_INK PEN <br /> Business Profile _ _ _ Tns ectlon Details <br /> TPID- InspectionType (Fill one) <br /> Site Suffix: -1(D 1 ( &Routine Q Re-inspection Q Referral Q Observation II <br /> Localif Referral,choose referral type(Fill one) <br /> S <br /> Identifier: ol VL `r0CL� '0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name inspected By Inspector ! <br /> ! Pec L)C C_ SLp)ol _ 1 <br /> Physical Address O `5' d lr°t 4tyLLLGLZ- + <br /> 5 �1fia A �� 2-Inspection Date <br /> q 9 I O <br /> `7 Time In �v Time Out <br /> Business Rep �J Title O AM O AM <br /> �SDY1 /�-0 vue, / O PM O PM <br /> — — - - - — -— -- <br /> Operational StatusTire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �,fJ (Fill one only) F(Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' f f 0 Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 indoor <br /> o Q Inactive ®Truck <br /> Longitude - Q Planned OTR o 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 60d ir,5 St eD�j� �a,4 i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ,;,, % ? ' <br /> y / fflm= /% j <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> PRC§42956-Registration/Decal in Vehicle 's <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 14 CCR 18459,1 a b c -Tire Program ID Number from CIWMB <br /> 14 CCR 18459,2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days r/ <br /> o Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years .. ' <br /> f0 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 J Q +14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments <br /> _ '15�2cfitan ('pnctyf +A;s t _ +f'YN�Q_ oQtaullvUS �'iZ1►�[ <br /> rc,,A). fir --waste �IIr s re-►tea\�e �l ov+'t r�ZIM i sus'� f f cu-1d atmos <br /> ` d�sir►bw;#-erg anal _d,i�ct�sse�� r �!a v�`° I a tLo� s , _ _ _ <br /> Inspection Form Included: Q <br /> Comments Included:Qr' ign � � ��� <br /> siness Rep's Signature Phone Number in actoature Phone Number <br /> INSTRUCTIONS BACK KIM �� �. A:I{�y p l 3 62081 <br /> yam.. i - �r <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />