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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of Callfornia <br /> Cgrated 1(teManage) Survey Form - Page 1 1 4 - 1 0 2 5 7 7 5 <br /> California Integrated Waste Management Board <br /> Part A- Surv_e rL_ _ _ _ BLUE OR R BLACK INK PEN <br /> Busliness Profile -_ inspection Details <br /> TPID- 4/. <br /> � � Inspection Type (Fill one) <br /> Site Suffix: � ® 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 Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Adds �E►� 3 l / <br /> w )�J1 a$lb`a�T <br /> Inspection Date D 7 fD <br /> j ' S <br /> Time In Time out <br /> Business Re Title O AM Q AM <br /> K QPM 0 P <br /> - Operational Status Tire Type Buslness Role Storage Type <br /> Tire Count(Whole/PTE) © (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I* Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> C Q Inactive O Truck <br /> Longitude - - Q Planned + Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair e 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-UseF acility <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q ' i � �/�ilY ''•� ,r <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. r <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements "> ; <br /> Q Q 14 CCR§ 184591 (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 day- <br /> 0 <br /> a sQ 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 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 /> Q Q <br /> Comments /��.�"Ti`�... ;5%+%�,'Y>•�r�- _1�Wj'rj-�r�'e-, � _ li✓+�-.� �T��. <br /> - <br /> _����i � � /�c-z 3 -d - �� lea.+►� _ �il%� , --- <br /> Inspection Form Included, Q <br /> Comments Included: - <br /> —sines Reps Signature Phone Number ecto na _ Phone Number <br /> - - - -- ry1A y�f� %//,� '? -- 62081 <br /> INSTRUCTIONS ON BACK ✓G ,, /I� ( X +�'IN'l 1. I ` � <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />