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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> -•rare State of California <br /> ClWMB f t(Now04104) Survey Form - Page 1 1 6 - 1 0 1 4 81 3 <br /> California Integrated Waste Management Hoard <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID_ et - C) / ;Inspection Type (Fill one) <br /> Site Suffix: O ` ® Routine Q Re-inspection Q Referral Q Observation <br /> i <br /> Local 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 /> Physical Address - l7 ( `�- tv 444 r- <br /> _ Inspection Date u US <br /> v\ 5- I� '_Sf.� Time In Time Out <br /> Business Rep Title O AM O AM <br /> A\ <br /> ��t �s 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 /> f O Q Active Q Passenger I*Generator ®Outdoor <br /> Latitude 0 Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer # 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFQRCEMENT$TATI71 <br /> V A.: HAULING AND MANIFEST REQUIREMENTS Q.Nottcs Qt.Vlolatf>7n Q A13 %r <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires �;4 <br /> Q 10 PRC§42953-Contracts with Registered Waste Tire Haulers. CompllonCe.Aeridl{na t <br /> O 10 PRC§42956-Registration/Decal in Vehicle m <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date.l <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Rtsgtr(n9e1#er.Ni�u>3rf} �.:� . <br /> O i O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years N ;ter <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q4�iy}rFAdl <br /> Q O 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators =AI <br /> / / ; <br /> O O Other: § �,, <br /> �. <br /> Comments 4LikA, ` i _(� v Ll r-5 <br /> Inspection Form Included: Q x <br /> Comments Included: Q / , - - - - -- - - - - --- -� ~ <br /> Business p's Signature Phone Number Inspe tor's ignat a Phone Number <br /> — _ 62061 - <br /> INSTRUCTIONS ON BACK c+DI'l�C�: .6- Ft.: M-(* V E )C A nth P l rr Y 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy;LEA ® ■ <br />