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t9 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> califomia Int graedfWase Management Board Survey Form - Page 1 1 1 . 1 0 1 3 3 2 3 <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business.Profile Inspection Details <br /> TPID- �r Inspection Type (Fill one) <br /> Site Suffix: 1 2 C1 D '7 5 - © Q Routine 9 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � 30Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> M L T"/, <br /> Physical Address <br /> �d Inspection Date 01+ <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> Q PM Q PM <br /> - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> 0 Active ®Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ®Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ®Container <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 0 Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility <br /> P Y <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> z. <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> -Y` S <br /> I d <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 Haulersz F` ^ <br /> Q Q 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 w <br /> Q 1 Q 1 Other: § a .. ... <br /> Comments _ ,,e.� GT1C�" Q' DT <br /> {� 5 1 <br /> ray, -+^ice <br /> e <br /> fiJfl ���.-fes -- <br /> !Inspection Form included:Q <br /> Comments Included:Q — <br /> us! is ep 1 t re Phone Number pector"s SignaTure Phone Number <br /> ■ INSTRUCTIONS ON BACK x A M P L ,2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA <br /> 0615104.0723 <br />