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tt,t Waste Tire p <br /> ec <br /> Ins&SurveyInspection Report Inspection Report Number ■ <br /> State of CaliforniaCrifi <br /> - at(New 04104) <br /> California Integra[d,Waste Management Board Survey Form - Page 1 ( 6 - 1 0 0 n 4 8 0 <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN.: <br /> Business Profile Inspection Details <br /> TPID- 1 - r Inspection Type(Fill one) <br /> Site Suffix: L ` 0 Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> IdentlBer: O CHP O CIWMB O Complaint O Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector Physical Address — l Q l ' l�r�e-,�•, <br /> �1 t5J Inspection Date <br /> Time In Time Out <br /> Business Rep Title / Q AM 0 AM <br /> 49 PM Q PM <br /> - � Operational Status Tire Type, Business Role Storage Type <br /> Tire Count(Whole/PTE) a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ®Active O Passenger l§Generator O Outdoor <br /> O O Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive O Truck <br /> Longitude _ O Planned O OTR O End-Use .O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service station Q Hauler O Agriculture O Shredder Other Lther <br /> Part B Inspection, of Waste Tire Dealer Generator Hauler and End-Use Facility <br /> O O PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal In Vehicle <br /> S_ <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting.Requirements ' <br /> a <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years '3 etas a ''fix' <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers g <br /> O O 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 x ''r <br /> O O. Other. § <br /> Comments 1�—�G,`1y1 <br /> W 31—7,? Entered <br /> 7 <br /> Inspection Form Included: <br /> Comments Included: 7 <br /> O' -�---- -s <br /> Business Rep's igna re Phone Number In o' Phone Number. <br /> L <br /> INSTRUCTIONS ON BACK d 1� P E E1 111213 62081 <br /> ■ - White Copy:CIWMB« Yellow Copy:Operator Pink Copy:LEA ■ <br /> 0529204. 1182 <br />