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trrr� ' Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ClWM f Calf.. Survey Form - Page 1 1 1 �- 1 01 3 2 4 0 <br /> CN4M8181(New OMed) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> .Business Profile Inspection Details <br /> TPID- Inspection/ f7! / Inspection Type (Fill one)Site Suffix: 1 3 (� ®Routine 0 Re4nspeclion 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> IdentMler -^ �agN, \ � ��D 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name L- Inspected B <br /> pact d y Inspector <br /> Physical <br /> O„\ <br /> dress <br /> �l <br /> / 1G Inspection Date O Z/ / 0-7 <br /> 15330 / <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <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 0 Passenger 0 Generator 0 Outdoor <br /> 0 ®Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - End-Use 0 Container <br /> 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Govemment 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 Fortes 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 0 Other: § <br /> Comments _ <br /> Inspection Form Included:0 <br /> Comments Included:0 LsInessRap's Signature Phone Number 1 gnature Phone Number <br /> INSTRUCTIONS ON BACK IEZIMIPIL E I Z 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy'.Operator Pink Copy.LEA ® ■ <br /> 0708104.0040 <br />