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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rr State of California <br /> Cgrated astde"an.ge Survey Form - Page 1 1 2 - 1 01 0 8 1 7 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: 7 / 0 Routine Q Re-Inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP 0 CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name U <br /> r <br /> Inspected By Inspector <br /> P� s <br /> suaa oZe-i <br /> Inspection Date Lo / Q / 0 7 <br /> �y Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> QPM— QPM <br /> s Operational StatusTire 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 /> r , <br /> •Active Q Passenger &Generator O Outdoor <br /> O <br /> GPS Latitude Q Closed O Altered .1/-/A <br /> 077'Q Hauler O Indoor <br /> O Q Inactive ®Truck <br /> Longitude – 0 Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ( Auto Repair O Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility f a` <br /> 0 7..'PRC§42951-Waste Tire Hauler Registration and Transport of Tires µ� <br /> O Q §42953-Contracts with Registered Waste Tire Haulers. <br /> 0 O PRC§42956-Registration/Decal in Vehicle t .� <br /> 0 Q 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 O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators z <br /> Q__0 Other: § ® "4' <br /> Comments Q�i'CA .>uv�- EJB � waj-{,� <br /> / fl �7'f cvQrk done <br /> J& P Q O' "f?4'�*m✓ `C6Zrc <br /> Inspection Form Included:0 <br /> Comments Included: <br /> uslness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK i EAj( AtM P 1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © . <br /> 41 L'SL�:},lll�'G1 <br />