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"eee <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CWMB 1st(New Manage) Survey Form - Page 1 1 7 - 1 0 1 4 8 1 4 <br /> California Integrated Waste Management Beard <br /> Part A- Survey BLUE OR BLACK_ INK PEN <br /> Business Profile _ I Inspection details <br /> TPID- 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 /> Business or Facility Name <br /> 1 _ i Inspected By Inspector <br /> Physic Add ess � � ` p `ir.�•,N �-t�u�G� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> t.l C � \' O 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 /> f f #Active ®Passenger ®Generator ®Outdoor <br /> Q Closed Q Altered <br /> GP,r Latitude Q Hauler Q Indoor <br /> C Q Inactive (§P 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 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 ®Agriculture Q Shredder Q Other 4 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFOR_EMENT STATU$ : <br /> V : A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Vitalaticrl <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compllonce Death no <br /> Q Q PRC§42956-Registration/Decal in Vehicle m ' •lir <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date I I / I` <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I I <br /> , <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (RegUlrBd for-N.V. <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years i ; <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Et6tet•rgd;l.x�f.A413 � �� �� �]�, <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 1 :/;;.% y <br /> O O other: <br /> XLComments 1 u-C'-t-S Q.t^C L oYk 1 Y-t XLL_S v, <br /> r D t l�1.�-�- k� i'�l,f k �r•�/h VA_D V,4J kl O l�� �1l k t �� U JAI I. LLR..- <br /> w�.> l 4- °1 > � t�Lt S i <br /> Inspection Form Included: Q <br /> Comments Included: - �-� l V ` \ \ <br /> Buslness Rep's Signature phone Number Ins ector's Signature Phone Number. <br /> ._. . -...........-�.. <br /> INSTRUCTIONS ON BACK Correct- Incorrect: ( �� � X A M P L � � � 3 62081 <br /> --- - _ - <br /> White Copy:CIWMB Yellow Copy,Operator Pink Copy:LEA <br />