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== Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> �ran <br /> i7. state of California <br /> Cgrated 1(New Survey Form - Page 1 18 - 1 Q 1 3 51 1 <br /> CalifOmlB Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �q � jaQ � i�:yD 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name — - — <br /> Inspected By Inspector <br /> Physical xre s lits <br /> �7 s <br /> [�,C Inspection Date / n f / O / <br /> Time In Timle Out b <br /> Business Rep Title O AM O AM <br /> C�r / �O�IYi _ _ - O PM QPM <br /> yr� <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 /> ' Active Passenger Generator <br /> ® 0 9 � ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair i®Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer Generator Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> t <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> a�. <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> �;+,�i1t���i Iris IIIY,; 1�1ti���1ii'`i3�'jt',I�'�� �ni•(F�G"�>wh�,fhf I <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities P <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 1 0 Other: § <br /> Comments 3 !�, LA <br /> /► <br /> !/l�ajs �','�5t'v�S_� l�g'�� 'C2� y'r•cd-- L��IG.� �r��'t�y'f.�.� �»"��'✓Y�C <br /> -pier k1, h <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> B ass Rep' SiPure Phone Number In ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK ,f T 3 ,, �4h p I 2 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />