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_i , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> t Slate B California Survey Form - Page e 1 1 fi 1 01 4763 <br /> CIWMB 181(New nage) r <br /> California Integrated Waste Management Board <br /> Part-A.-Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 f1 Z Z — Routine Q Re-inspection Q Referral Q Observation <br /> Local �T If Referral,choose referral type(Fill one) <br /> Identifier: �4 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> i ' Inspected By Inspector <br /> Physical Aildress <br /> 316 A) Hwr99 <br /> `"A /72#0 Inspection Date t Z,. I 3 G <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ' O PM O PM j <br /> D-i� �4Y'I hta Operational Status Tire Type Business Role Storage Type Il <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply); <br /> Active O Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0Q Inactive *Truck ' <br /> Longitude — I Q End-Use i Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair . 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 /> 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 ENF9 G„ JC Mr I <br /> '`-: Wi ll ,fitf#A�4414tr►t�ll >gTREQUIROMENT9 <br /> Q Hatl�aan+�I# � t <br /> Q Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires r / <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. GptTl(<tll�tlrfi�`-1;IfM <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWM$ <br /> Q O i 14 CCR§ 18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> I <br /> 14 CCR 18459.3-Retention of Manifest Forms and Tire Trip 1C <br /> s for 3 years ""`»"'""�✓ '�/ '%'/ 'i f <br /> Q O 14 CCR§16460.2-Manifest System Requirements for Registered Waste Tire Haulers Q P��pr ✓, r f � i� .. <br /> Q O 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 O Other: § `F'y !,= <br /> Comments LJa9fz_ 4� k1i-II <br /> 04 — 0q 07,1 t L4-(7-7 itcv e, PA Imo-- Ave, J"4DO&5�_o q5;-35 j <br /> Inspectlon.Form Included: Q R <br /> Comments Included: d _ `�'�^Z� <br /> Business Rep's ignature Phone Number ins ct r s 1 nature Phone Number <br /> INSTRUCTIONS ON BACK . <br /> 62081 <br /> � ::� X �' P L E 2 3 <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />