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=ir Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stan or California <br /> CrWMB <br /> California lntng hadrWanN81 e Management Boartl Survey Form - Page 1 1 7 - 1 0 1 3 1 5 5 <br /> Part A-Survey _ _ BLUE OR BLACK INK_PEN <br /> Business Protlls Inspection Details ID- Inspection y ` n _ Inspection Type (Fill one) <br /> site Suffix: y !— — �j `� 0 Routine 0 Reinspection 0 Referral 0 Observation <br /> Lod If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - - - - <br /> 4 ��d��+'t Inspected By Inspector <br /> ,4 <br /> Physical Address 3 9 <br /> Inspection Date Q z / Q / 7 <br /> lam' Time In Time Out <br /> Business Rep p Title Q AM Q AM <br /> l�-� �-t✓'G �/Y�! �,C � QPM QPM <br /> Operational Status Tire Type ype Business Rale Storage Type <br /> - <br /> Tire Count(W hole/PTE) 2 S- (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r _ J 0 Active I*Passenger 9 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ID Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude _ 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 4D Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body •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 /> O 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O 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 /> i <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q 1 Other. § <br /> Comment; A&t <br /> 0�� `1/�J'I'c �Arp✓s-/�j� Lr�•(��/�s�^L <br /> �vi�-li-,S i�-•d s- A <br /> Inspection Forth Included:0 <br /> Comments Included: <br /> -— <br /> Buell a Rep's Sig Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK _ E X A AA P L E 1112131 62081 <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy LEA © ■ <br /> 0708104.0049 <br />