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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of Callforn la <br /> CWMB grated 1st(Now Manage Survey Form - Page 1 l 6 - 1 0 0 8 0 4 7 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> [Business Profile - 1 Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / l [ 3 7 - d ( e Routine Q Re-inspection Q Referral Q Observation <br /> i <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> i <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Au e- <br /> ��� �� ����� •; Inspection Date D -7 / j <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0P 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 62, 6 f0 -C �� (Fill one only) (Fill all that apply); (Fill all that apply) (Fill all that apply) <br /> v Active 0 Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 ENFORCOM91JT STA' l75 <br /> V ! A HAULING AND MANIFEST REQUIREMENTS <br /> O to :PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O N004 0V.W0*tl�a <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. G9mpllAnR Q+gtlf} i <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 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 Tri Los for 3 ears % <br /> § P 9 Y �. <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q woij' i-44, <br /> Q O 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 O Other: <br /> Comments 1 l//� <br /> c� , 1 tom` ��-fit-. • �i i�' l5v f'�a/5 uo el 4� <br /> CSI i ve,,�>✓p b �� I 09241 -res „ y AJD rMa f^t-�s 4­5 <br /> � -�-- <br /> y <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's S tura Phone Number� ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Cgs � t (V) A jlrl P j (, l 62081 <br /> White Copy.CIW Yellow Copy:Operator Pink Copy:LEA <br /> ■ <br />