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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> Cgrated 1tteManage Survey Form - Page 1 1 8 - 1 01 4 8 6 6 <br /> California Integrated Waste Management Board <br /> Part A--Survey BLUE OR BLACK INK PEN <br /> Business Proflle Inspection Details <br /> TPID- r Q Inspoction Type (Fill one) <br /> Site Suffix: ! 'f-� Z Z ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��1h J Uc,ge�.l �NN �. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name h Inspected By Inspector <br /> Physical Address <br /> Av e— <br /> Inspection Date d <br /> 7sw-� <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 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 /> r ' 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 • Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> I _ � <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 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 /> _---- <br /> y,..,.::....y... <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCI1M 8TATI <br /> si/1� <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- 0 Notlw Ql 1Iil�Qrt <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. CompllettCq'DNdll[Ier1i i= <br /> 0 0 PRC§42956-Registration/Decal in Vehicle "` '` <br /> 0 0 14 CCR§ 18459 Responsible Entities Complying with Manifesting Requirements Dab <br /> 00 'V 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 �� fyis`i� <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 `y ;,"..•:. " ;` x'��/� <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § IB <br /> Comments <br /> NO -�/-e, s 1� <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number ector's Signat Phone Number <br /> INSTRUCTIONS ON BACK _Cot =:InaQr E X A Mt I P I L E 13 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />