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�E Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CIWMB <br /> Survey Form - Page 1 1 7 - 1 01 3 51 <br /> CM/Me 181 stew nag <br /> CalHomia 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: I a s 5 a O I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localn If Referral,choose referral type(Fill one) <br /> Identifier: s rl" JIQ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> T <br /> Physical Address -I — I o1 'TQ,(rL <br /> aLf c- M � - - <br /> Inspection Date <br /> S c�fa►� 0 4 g 5 '05 0 <br /> Time In Time Out <br /> Business Rep n/�^ Title �j � O AM O AM <br /> 1\UCI�r� ("lW�� �- �r. Di' �`�A C.„v� — 0 PM O PM <br /> JJ/ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> Will one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q (9-Active Q Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 1 Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> i Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § [ , <br /> Comments Z (_ C_IWN 5 (��JC Was �W 11°�I\S �� <br /> -- <br /> V,s WI Ism k6l Tre- fo 6U15 ode -6Ts v lewd exvan r <br /> 1)ra leo - - 'Sig=ib eat a+�d ol,�s c c�s&�(- a ✓lot ams <br /> Inspection Form Included:Q �V/ 19 <br /> Comments Included:Q <br /> Business Rep's Signature _ Ph ne Number _I s ors, afore Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPI L 1112 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0622804.0434 <br />