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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State California <br /> CIWMB,9astlegSurvey Form - Page 1 7 1 0 1 3 1 8 8 <br /> CalHomla 6ttagrated Waste ManaManageeent mBoard <br /> PartA-Survey - - - _ BLUE OR BLACK INK PEN <br /> Buslness Profile Inspection Detalls - - <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: 3 3 9 g ,Z C / Routine <br /> - - 1 Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: _ <br /> �L �GiC,-Cta�f O CHP Q CIWMB Q Complaint Q Educational Visit O ether <br /> Business or Facility Name U — <br /> Inspected By Inspector <br /> Physical Address ✓ <br /> 31Z12_3 .5. <br /> s4v4� u/ /.� Inspection Date O ( / / / <br /> Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Pili one only) (Fill all that apply) (Fill all that apply) (FIII all that apply) <br /> - •Active 0 Passenger ®Generator 0 Outdoor <br /> GPS Latitude <br /> O Q Closed O Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude <br /> • Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) --- - - - - - -- <br /> 9 New Tire Dealer Q Auto RepairQ Trucking Fleet Q GovernmentQ Retreader � Dismantler O Tire Fuel <br /> — <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. � • <br /> Q O PRC§42956-Registration/Decal in Vehicle k � t <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 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 <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ' <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O 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 /> O 1 Q Other: § <br /> Comments 41--- <br /> Qe."�� � La,E,h %�� �o reu�a d� w� 4�;•y GtG�-><c ,,�.rte— <br /> ruuorP� — <br /> o <br /> Inspection Form Included:Q <br /> Comments Included:Q k�O.Odmoi AIL— <br /> ssRep's Signature _Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK x r P E 1 . 3 <br /> ■ White Copy:CIWMB Yellow Copy.Ooerator Pink Copy:LFA, ® ■ <br /> 0711604.0133 <br />