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=ts, Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of CelRomid Survey Form - Page 1 I Z - 1 0 3 3 2 4 <br /> r IwMa 18 <br /> 7(New nagd) <br /> Califomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> ffi <br /> Site Sux' r 2 T L 7i ®Routine Q Re-inspection Q Referral Q Observation <br /> i <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier ?hr,; ./eQ CHP Q CIWMB Q Complaint Q Educational Visit <br /> 7 Q Other <br /> Business or Facility Nam Inspected By Inspector <br /> -4 *— / <br /> Physical Address '3 Q j ]fL <br /> 4� <br /> s7s7 <br /> Inspection Date Q Z p b0-7/ Time In Time Out <br /> Business Rep Title O AM O AM <br /> •PM O PM <br /> OperatfonalStatus Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one on <br /> (Fill all that apply) (FIN all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ®Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O <br /> Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-use Q 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 O 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 /> 707(_� !R42 1-Waste Tire Hauler Registration and Transport of Tires <br /> 3-Contracts with Registered Waste Tire Haulers. <br /> Q O. PRC§42956-Registration/Decal in Vehicle <br /> Q 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§15459.2.1-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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q (Other: § <br /> Comments vn ' <br /> / o S.,jos OR f is s;&_ - - <br /> Inspection Form Included:Q' <br /> Comments Included:Q <br /> Buslness Rep's Signature Phone Number Iniqll Signature Phone Number <br /> INSTRUCTIONS ON BACK E X A M P L E 1 2 3 s2os1 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 5605204.0547 <br />