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i1== Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 1(Now nage) Survey Form - Page 1 1 5 - 1 0 0 8 046 <br /> California 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 /> Site Suffix: / I&Routine Q Re-inspection Q Referral Q Observation <br /> Local , C C5 6 5 q l If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Phy �..I&Adteress <br /> ^ Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM O PM <br /> Operational 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 /> 0 Active ® Passenger ®Generator *Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — 10 Planned Q OTR Q End-Use Q Container <br /> 1 <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Relreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body &Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler IQ Agriculture Q Shredder Q Other <br /> I <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFQRQ MILNT:.STA <br /> V! `• A HAULING AND MANIFEST REQUIREMENTS 0 NoNt:e.Qf Vlalftian OsxtenIelt <br /> 10 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ( - <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Gompllln�9 Deadllrt� <br /> O O PRC§42956-RegislrationlDecal in Vehicle m <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date I ` I <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program)D Number frorn CIWMB L r�--- <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (R9gtrlrafs>rN4�grkll <br /> 00r <br /> t <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O I O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers �} geferrr / 4� jtf�f{ t��J3# <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: <br /> Comments /1/'I N'► )�"� l�'�p I ©I''►S!�L''- » ��[�� ' �'✓�S't'" <br /> Inspection Form Included: Q <br /> Inc dad: <br /> Commentslu gu f ess Rep's <br /> 71 In re Phone Number or's Sig ere phone Member <br /> INSTRUCTIONS ON BACK I Corr 1 rrget: A� N% E fl ,MI�PTj L�E �l L3� s2aa1 <br /> White Copy CIWMl <br /> Yellow Copy:Operator Pink Copy:LEA <br />