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�z€ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 5teteoornia Survey Form - Page 1 1 2 1 0 5 1 4 <br /> CIWMB 181787(New 04104)California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 31 -'7 y 6 b ( Q Routine Re-inspection Referral <br /> _ _ � P Q 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 7 - <br /> ,�G Inspected By Inspector <br /> Physical Address 3 <br /> LH4'2— <br /> /— <br /> Inspection Date 0 3 / 2- <br /> Time <br /> Time In Time Out <br /> BJus�iness/Rep Title O AM O AM <br /> O PM O PM <br /> - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / C) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®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 Dealer Generator,Hauler and End-Use Facility <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 /> Q Q PRC§42956-Registration/Decal in Vehicle ' <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements r, <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> i< <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 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 ` <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q Other: § ° <br /> Comments i/f es 2 & _ <br /> If All <br /> Inspection Form Included:Q <br /> Comments Included:Q - o! <br /> Business Rep's Signature Phone Number Inep tor's Signature Phone Number <br /> INSTRUCTIONS ON BACKA 62081 <br /> White Copy CIWMB Yellow Copy Operator Pink Copy:LEA <br /> L_1 r, <br /> 15104,0574 _ <br />