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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of <br /> CIWMB <br /> Survey Form - Page 1 1 5 - 1006669 <br /> CIWMB 181181(New adage) <br /> California Integrated Wase Management Board <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: j 7 y 9 / Q 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: �Qn V�Q � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Busin7 or Facility Name Inspected By Inspector <br /> Physical Address 3 9 / O Jc�-fy�g;y/ -✓/}, <br /> d-2/ <br /> Inspection Date <br /> Time In ( Time Out <br /> Busiin^ness Rep Title rI-- 19 AM ) G AM <br /> 1.2 <br /> OpereTire Ty <br /> tlonal Status pe Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> r 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor AA <br /> O 0 Inactive 0 Truck <br /> Longitude _ 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ( New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B Inspection of Waste Tire Dealer Generator,Hauler and End-Use Facility .. u <br /> v� g <br /> 0 0 yPRC§42951-Waste Tire Hauler Registration and Transport of Tires N c a <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> PRC§42956-Registration/Decal in Vehicle H <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements . <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB .,, <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 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 /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities r <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators : .- <br /> 0 0 <br /> Other: § <br /> ,Ared arc- ~reg/ <br /> Inspection Form Included: 7 T- L'p� <br /> Comments Includ C S�—r ^'� <�� l� Q k"Oy? <br /> Rep's nat Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK 1EVAIMIPILIEf 111213162081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br /> E�6284c4.A0 <br />