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Sf P7 <br /> Waste Tire Survey & Inspection Report .;_Inspection RePort Number <br /> »� State of California <br /> CIWMB 1E7(New a Survey Form - Page 1 , <br /> CaliforniaalIntegrated Waste Management Board - <br /> 8 -- - <br /> - - fi 4 <br /> -Part A-Surve BLUE OR BLACK INK PEN <br /> tnspactlonastali- — — <br /> TPIDf s_... i Inspection Type (Fill one) <br /> Site Suffix: f i <br /> 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local i 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 <br /> 1L _�!]l� I <br /> /ee <br /> I t INtGCgt -1 <br /> f I <br /> Inspection Date <br /> Time In / Time out <br /> Business Rep Title —! E-- - - O ANI I i. - O AM <br /> l I• rO 0 PM 1 O PM <br /> �O k l\GVH - <br /> -- Olpeotatioon y>Status ��lea Khpe at apply)I Business Role Storage Type <br /> (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 5 p <br /> t � ®Active ®Passenger O Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler .Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type.(Fill all that,aPPN) <br /> Q New Tlre Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ®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. <br /> Q O 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 /> O O 14 CCR§16459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0 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 /> 0 O 14 CCR§.18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q j 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 10 :Q. -- <br /> Comments' ��J� ��.�y'^.qy�.�� '��y7. -• <br /> ......----- a <br /> L—Atllr IIKµST �slO _ \re4 6�re.n.rT O� —I+N <br /> Inspection Form Included:0 <br /> i Comments Included:Q - <br /> Business ftep'a Signature. Phone Numbilr ,. .Inspe re �.Phoft Number_ <br /> INSTRUCTIONS ON BACK. :E X A Mt P E� 62081 <br /> ■ WhlteCopy..CIWMB Yellow Copy.Operator Pink Copy:LEA ® . <br /> 0525804.0167 <br />