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r , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Crate WMB California Survey Form - Page 1 f 8 • 1 Q 1 31 4 8 <br /> CNYMB 781(Naw 01/04) <br /> CelHomla Integrated Waale Management Board <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> �TPID <br /> uslness Profile Inspection Details <br /> - , O , Inspection Type (Fill one) <br /> Site Suffix: i Routine O Re-inspection O Referral O Observation <br /> Local �-_ If Referral,choose referral type(Fill one) <br /> Identifier: sem` fpQ3r Q CHP Q CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - — <br /> l/ Inspected By Inspector <br /> .Physical AAress <br /> 63/8 <br /> ��&2�, 07 <br /> Inspection Date C Q <br /> Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> 0 PM 0 PM <br /> —Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 40 Active •Passenger 0 Generator 0 Outdoor <br /> D d O CloseI0 Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> D O Inactive 0 Truck <br /> Longitude _ O Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet 0 Government O Retreader 0 Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer O Auto Body 0 Car Dealer O Collection O Crumb Rubber <br /> Q Service Station 0 Hauler 0 Agriculture Q Shredder 0 Other �r�� /v—.�Mc4j'" <br /> I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O Q 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 <br /> O 0 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 /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O Q Other: § <br /> Comments /�D[t/51..2 i/+f/ �Av dr-�t'�ksfr e�Y LqAxp <br /> / <br /> Inspection Form Included: _ Yoo <br /> Comments Included:QA�ness <br /> ��ep's Signature Phone Number Inspector's Signature Phone Number <br /> 062081 <br /> ■ INSTRUCTIONS ON BACK IEIXIAIMIPILHE I1,ZI3I ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0708104.0048 <br />