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�i Waste Tire Survey & Inspection Report Inspection Report Number <br /> SlateSurvey Form - Page 1 1 $ - 008098 <br /> CIWMBBCaliforniaCa(New 04104) <br /> Californla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile i Inspection Details <br /> TPID- 1 Inspection Type (Fill one) <br /> Site Suffix: \ - #Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Buslness or Facility Name Inspected By Inspector <br /> _ ` ( <br /> Physical Address i <br /> 5 i <br /> q Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM I <br /> (w fO( G <br /> ` � Uz-vleOperational 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O ® 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 ® 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 <br /> y�Dealer, Generator, Hauler and End Use Facility <br /> owi slat, <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. �( <br /> - • x <br /> Registration/Decal in VehicleQQPRC§42956 <br /> t- <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying wlth Manifesting Requirements <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q 1 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years e. 1, A4r �F <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers _ <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Oi,.- <br /> 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators f •" - <br /> O 1 On <br /> Other: § ���'�„��%•.,�9rs.��f r,,n'�^ , _,. <br /> Comments %A-)f� <br /> Inspection Form Included: Q <br /> Comments included: Q -- e��"' )_75 `��� <br /> - Iness Rep Signature Pho ie Number Ins ector'spS�i`gnature Phone Number <br /> I` i �'�r 62081 <br /> INSTRUCTIONS BACK E<?c Q ,, c I 11 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />