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Waste Tire Survey & Inspection Report Inspection Report NumberStat ■ <br /> fornia <br /> clwmBc8l(N.w Survey Form - Page 1 1 7 - 1 01 3 4 9 3 <br /> CIWMB 781(N.w 04/04) <br /> call"mia Integrated Wast.Management Board <br /> Part A-SUrve _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID• �� O S _ O / Inspection Type (Fill one) <br /> Site Suffix: _ 0Routine QRe-ins Re-inspection <br /> Q Referral 0 Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: h (� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P y Inspector <br /> Physical Address 3 <br /> /3 a20 pe r 0e r /0r - -- — -- - - <br /> <��� Inspection Date <br /> Time In Time Out <br /> Business Rep Title / AM AM <br /> �7- D 2 S 0 PM O S O PM <br /> /taw, lnod, .r /C r It .G <br /> - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> v� 0 Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive fo Truck <br /> Longitude — Q Planned Q OTR Q End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment 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 0 Other {^+ �C �/d A,.& <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Hill �T <br /> Q O 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 114 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 11 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § <br /> Comments kt2 i hp 40. DSI alt/1' L� lk+ae 4 c r' �rJ 4d 4w 1_ <br /> Inspection Form Included: <br /> Comments Included: —fid V*411 <br /> Business Rep's Signature. Phone Number Inspector's Signature _ Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI 111213162081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0618604.0025 <br />