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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> clwM f181IN— Survey Form - Page 1 i 9 - 1 0 1 3 3 2 2 <br /> CIWMB 1a1(New mg <br /> Cellfomla Integrated Waste Maregement Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q 1 3 - a t 0 Routine 0 Reinspection 0 Referral 0 Observation <br /> Local4, V If Referral,choose referral type(Fill one) <br /> Identifier: ` 0 t ) O CHP Q O CIWMB Complaint Educational Visit Other <br /> I1r J�{in�..� V- <br /> Business or Facllity Name Inspected By Inspector <br /> Physical Address C> s <br /> Inspection Date 0 -5 / 0 6 / o b <br /> � Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> /"sllr-Iry�ps / 'C� <br /> -- -- - Operational Status Tire Type Business Role Storage Type I <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> f f •Active 0 Passenger 0 Generator 0 Outdoor <br /> - - _- 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that appy) <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 /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 i 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§16459.3-Retention of Manifest Forms 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 /> 101 0 1 Other: § <br /> Comments <br /> r+9 <br /> _!94L 14-;91-,lrri �/cJiG*— <br /> ff <br /> Inspection Form Included: MAO <br /> Comments Included:0 7f 0 r 16��Zg4 <br /> „r/ <br /> Busi ss R46 gnature Phone Number In torsSigna ure Phone Number. <br /> INSTRUCTIONS ON BALK IIEIXIl0.lAkIPILIE1 111213162081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0609004.0060 <br />