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Waste Tire Survey $ Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 1 2 - 1 0 1 3 6 7 0 <br /> CIWMB 1 B1 INew 04/04) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 O 7 / 3 Y I - 0 Routine Q Re-inspection Q Referral O Observation <br /> Local , _ // If Referral,choose referral type(Fill one) <br /> Identifier: 1,11—A V�Q�'��h 0 CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> l��p <br /> /'Pa' <br /> Inspected By Inspector <br /> Physical Address <br /> x/77 <br /> Inspection Date 0-9 / / (D 61,(f' Time In Time Out <br /> Business Rep Title ? Q AM (� 0 AM <br /> /7 C / '�/a� del t�G.-1 / J / O 0 PM J / 0 PM <br /> Operational StatusThe 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 /> 0 Active O Passenger 0 Generator Q Outdoor <br /> 0 O Closed O Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 O Inactive 0 Truck <br /> Longitude _ O Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair i Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q service Station O Hauler O Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End Use FacilityY <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires r,. �r a +.f <br /> ca,s <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. - <br /> OO � � <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days o " <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities s <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> - <br /> O O Other: § <br /> Comments <br /> q/ ^U ,-amu - , �:-•> y� recs� <br /> Inspection Form Included:O <br /> Comments Included:Q <br /> Bus as Rep's latur Phone Number Inspector's.Signature Phone Number <br /> INSTRUCTIONS ON BACK IX JAIMI P I L E 12 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 06 4904.t_1182 <br />