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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> s""°"'n'°`°" Survey Form - Page 1 f1 - 1006590 <br /> C , <br /> CalHomia InfeQraled Waste(New 0u ,Management board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 4 /' Inspection Type (Fill one) <br /> She Suffix: L+ 2 Z l`7 _ 0 l ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: fir,7:�,14— CPQ4 <br /> EHD Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> /_ Inspection Date O -7 t [1 b ^7 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fin all that apply) (Fill all that apply) (Fill all that apply) <br /> ° r Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude ®Closed Q Ahered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 1 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 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 /> Q t Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers, <br /> Q Q PRC§42956-Registration/Decal In Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 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: § n(� <br /> Comments ✓� f s �� G1 I�cX S <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's.Signature Phone Numbe_r _ tors Sig ire. Phone Number <br /> INSTRUCTIONS ON BACK JEWIAIMIPILIE 1 2 <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® . <br /> 0708104.0173 <br />