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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CIWMB <br /> Survey Form - Page 1 17 - 0 3 3 9 4 <br /> CNYMB 187(New nage Y <br /> California Integrated Waste Management Board <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ) L Inspection Type (Fill one) <br /> Site Suffix: / - Z `/4 E) Q Routine Q Re-inspection Q Referral (0 Observation <br /> LocalIf 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 /> Inspected By Inspector <br /> _.j,{/� <br /> Physical Ades <br /> 1 <br /> �U <br /> CIA <br /> Date / / c <br /> � Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> O PM Q PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator •Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> o � Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 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 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 ' <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <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 3 <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities 4h ' <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ' x <br /> Q Q 1 Other: § 1 n <br /> Comments 11 -1-4, �r�/S Gi t�LQASRs re.fC La le,, j2I G_ V•I7 I <br /> _GOrpt�r-rn-'�z— t7't^f-Ic.�- 1•— c �'o,--. � nh� u�...✓-K'.4'T�- <br /> - �--- <br /> Inspection Form Included:Q <br /> Comments Included: �bg�Zs <br /> s ess ep's Ignature Phone Number In tor's Signature _Phone Number <br /> INSTRUCTIONS BACK lErXIAIMIPILIE1 111213 62081 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA © ■ <br /> 0 G 15 1 C 14.F,7_24 <br />