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Waste Tire Survey & Inspection Report Inspection Report Number <br /> state of California <br /> Cgrated WasteManagementSurvey Form - Page 1 9 - 1 0 2 � 0 <br /> Callfornla 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 /> ISite Suffix: 1 C7 \ I�{ Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier; Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name I Inspected By Inspector <br /> C-Ct TT�- V S - <br /> Physical AEf ess <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> Operational Status Tire Typo Business Role Storage Type <br /> .� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> f f �Active ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 0 indoor <br /> O Q Inactive 4 Truck <br /> Longitude – Q Planned Q OTR 0 End-Use ®Container <br /> i <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> • Part 8-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility i ENFORCEMENT STATUS <br /> f fQ Notica Of VI IMIGn Q Eztenoton <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires I ff <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Cp111pIip1145:DYpcfilp0 l <br /> OI O PRC§42956-Registration/Decal in Vehicle I j <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Qate ' I m <br /> Q I Q 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q I Q 114 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days I tFtoaufred f01 NavCrfSf(f <br /> { `! i <br /> O 1 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years L <br /> Q II Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers .Q fsdrets fIYSr1fOr0�n70nt <br /> d ! Q 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ,r <br /> l Q Q 14 CCR§16462-Manifest System Requirements for Tire Dealers or Waste Tire GeneratorstT <br /> �� �.rw <br /> Other- k ii, <br /> Ms <br /> Comments w�k� , bru 5 �{� tµ t7 _ .Stl �y JtA t�-?�— rt,'0 <br /> VA V— <br /> Inspection Form Included; Q �b���f'/� <br /> Comments Included;Q ,y// '/'—�la►r �t h <br /> Business Rep's Signature one Number Ins ctor's Signet re Phone Number <br /> INSTRUCTIONS ON BACK �1`'eAI'j i � 1 `� � � A JJV1E'�L E� �tT2 33 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> J <br />