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Waste Tire Survey & Inspection Report Inspection Report Number <br /> stato of CrWMB <br /> C,INomla <br /> CnNM8181(New Odxld) Survey Form - Page 1 1 4 . 1 01 31 9 3 <br /> Calltomla Integrated Waste Management Board <br /> P_art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O / 6 Q O / Inspection Type (Fill one) <br /> Site Suffix: 7 Routine Reins action Referral <br /> _ � O P O O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��� �� jt Q CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 3 9 i .�GtQ,C39 s'`�t// I✓.0 <br /> Inspection Date <br /> Time In Time Out I <br /> Business Rep Title Q AM Q AM <br /> 0 PM 0 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 /> t i Active Q Passenger ®Generator Q Outdoor <br /> — D Q Closed Q Altered I <br /> GPS Latitude Q Hauler IS Indoor <br /> O Q Inactive •Truck <br /> Longitude – Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair I&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 Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O Q Other: § <br /> Comments >44K 1 wd✓ Lerr.' <br /> �^�►"�'� x`91 %,�.5' � ��o� _ s�r� �->7�. '_.(° ����� <br /> -- <br /> Inspection Form Included:Q'_— <br /> Comments Included:Q <br /> il <br /> ness R s Sig re Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK IEIXIAIAkIPIL 2 62081 <br /> 0716504.0028 White Copy CIWMB Yellow Copy.Operator Pink Copy LEA ® ■ <br />