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■ Grp; Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of mla Survey Form - Page 1 I fi 9 41 31 7 9 <br /> CNVMB 181 781(New <br /> OM <br /> CalHomia Integrated Waste Managege <br /> ment Board <br /> Part A-Surveil BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> f TPID- Inspection Type (Fill one) <br /> Site Suffix: / 3 /-7 7 0 I <br /> _ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local J �J'� !� If Referral,choose referral type(Fill one) <br /> Identifier. SlName C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> P ysical Address - tJ <br /> -S013 6 vTNi 40 vl� <br /> Z-,)_ Inspection Date (� 1 7 <br /> 7 r Time In J Time Out <br /> Business Rep Title O AM Q AM <br /> O PM O PM <br /> —'Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger Generator <br /> � ® g ® 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q 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 /> `7 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (a Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility = <br /> I <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 <br /> G(CG/y,7 <br /> CLZEi ff � f i%p- LrI?1�J'L /L/xiJ,� Zj <br /> �y � �l w� �i rte 1/taifj.Ls) <br /> '9 <br /> J-s l' 44 4 r e�vl.� >'t.1 `t 4�.[tea✓ i a.c cc.'J4 2�" G`e' <br /> Inspection Form Included:Q.• <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ll�'!. �,I i IEIXIAIMIPILIE! 1112131 s2081 <br /> ■ INSTRUCTIONS ON BACK i � ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0710204.0209 <br />