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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State California <br /> Cpurvey Form - Page 1 2 - 100 $ 002 <br /> CIWMBWM5 181(Now 0410A) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: D D 7 0 7 a I• Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: �� p k�. � O CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> `Business or Facility Name <br /> inspected By Inspector <br /> fkb . <br /> Physical Address <br /> Inspection Date D g <br /> � rte• � y���'� I -� � <br /> lTime In Time Out <br /> Business Rep Title O AM O AM <br /> ' O PM O PM <br /> Operational Status Tire Type j 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 /> •Active 0 Passenger 0 Generator •Outdoor <br /> C 0 Closed 0 Altered <br /> GP$ Latitude 0 Hauler O Indoor <br /> 0 j 0 Inactive 0 Truck <br /> Longitude — O Planned O OTR O End-Use •Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer O Auto Repair 0 Trucking Fleet O Government 0 Retreader 0 Dismantler O Tire Derived Fuel <br /> I Used Tire Dealer 0 Auto Body 0 Car Dealer O Collection O Crumb Rubber <br /> 4 0 Service Station 0 Hauler O Agriculture 0 Shredder 0 Other ` <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORC ANT$TAT11$; <br /> y �*A HAUI.INQ AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Vlalalltitf Q_f;>1fl�ftlt?rt <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compllanae ReBdllne ' <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Des / <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 (Rei7ulreallr�rN,"lvatX7� <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 O Rf�ferrltq���t' r Y <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities y <br /> 0 0 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators < <br /> O Irl Dfitll �! t <br /> 0 O "Other: § y! <br /> Comments 1,�a '�/�1 \ � � o� �r��� O\ L�v�C2V'✓\ 0.` �T'�1N�� �� <br /> IInspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone(Number lnspa ure Ph/one Number <br /> .--�-- --r.._ 62081 <br /> INSTRUCTIONS ON BACK I Correc . In�orrgct• ( . E X A M pf L EI I i a <br /> ..X ,CE IC �T..��I�� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />