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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> ClWMBrCalifornia SurveyForm - Page 1 1 5 - 10 14 75 4 <br /> CIWMB iBi(Now <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile. _ Inspection Details <br /> TPID• 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: 9� J dq��N�� �y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r <br /> ' Inspected By Ins'pe'ctor <br /> Physical Address <br /> S f S LF `fuse,,,,;4-r_ )q v <br /> Inspection Date <br /> GA C?533& r T <br /> Time In Time Out <br /> Business Rep Title Q AM O AM <br /> O PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> TIFB Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (FIII all that apply) <br /> r Q Active Q Passenger Q Generator Q Outdoor <br /> O ®Closed j 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 /> i I <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 /> 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 l ENFORC4MENT$TATU$f <br /> Y �,j_IHAUti -G AND eMAIA EST REQUIREMENTS <br /> Notice Cf ylQlaki n N � <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q marl#Itln <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Cnmplianes Dgsldlfne <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB ED <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (R�IulradiJfuaPh>?'�J '. <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> i <br /> Q i Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers (� R9NtJrgs!f D1K61d� <br /> Q Q '�� 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ s J � <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Qin � ?tr� �n y�� i <br /> Q Q .Other: § <br /> Comments 5 1 C_ fS Gtnrrms41R ' <br /> /)U 1M54,e__/ / �4 <br /> Inspection Form Included: <br /> Comments Included: Q - - <br /> Business Rep's Signature Phone Numb/erg n or's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK �Cq f� Ino61T*6 ( {v) , X A 1M P t_ E � ® ■ <br /> White Copy CIWMB Yellow Copy Operator Pink Copy.LEA <br />