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use Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r <br /> State of California w . <br /> CIWM61g1Mana(NegSurvey Form - Page 1 8 $5 <br /> California Integrated Waste Manageement Board - <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- n f _ Inspection Type (Fill one) <br /> Site Suffix: J 1 ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �p� CW' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V -G V <br /> RbcInspected.By Inspector <br /> Physical Address <br /> Q 3. -t <br /> fie- <br /> /)^nQ� n/ ^� Inspection Date , (� I O <br /> J V'W /VT C_A! Time In Time Out <br /> Business <br /> `Rep <br /> ,,, Title 0 AM O AM <br /> Q PM Q PM <br /> �/ - Operational Status Tire Type Business Role Storage Type. <br /> Tire Count(Whole/PTE): (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> f 0 Active 0 Passenger 0 Generator 0 Outdoor.' <br /> O Closed ered <br /> GPS Hauler <br /> Latitude 00 Alt0 indoor <br /> O 0 Inactive 0 Truck <br /> Longitude 0 Planned O'OTR 0 End-Use 0 Container: <br /> Business Type (Fill all that apply). <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 1 0 Other: § <br /> Comments r p t <br /> IV- <br /> NO <br /> Inspection Form Included:0 n r ra <br /> Comments Included:0 i / nN� <br /> siness Reps Si re phone Number spector' Signarure Phone umber <br /> . INSTRUCTIONS ON BACK LY I, A Mf1`ILFEI iiliJ3 62081 <br /> 07165$4.$$57 White Copy CIWMB Yellow Copy:Operator Pink Copy:LFA ® ■ <br />