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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> /1r Stat.of Calif—la <br /> CIWMB 181(N..04104) Survey Form - Page 1 15 . 1 0 1 3 3 3 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: Q Routine ®Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r CHP 0 CIWMB 0 Complaint 0 Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector 1 <br /> Physical Address <br /> ^ - 11 Inspection Date /L / 2 ' / 6 <br /> �� C/ �, Time In `T Time Out <br /> Business 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) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' •Active 0 Passenger *Generator 0 Outdoor <br /> C 0 Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> �Inlactive 0 Truck <br /> Longitude - ned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> JR 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 5`= <br /> 0 Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires f air z ' <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <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 •..' v, <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities 4 " <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § <br /> /� e ' <br /> Comments fU'-��Y Ofl�(i✓W�/ rv-� r 15 �T 1t1 - �/jd 3 . ��••r f¢e <br /> "GT-L.. (r— -: <br /> Q"¢�1(Je_,e3 I <br /> 136 l (c� r lS ( u--tl �.zyio�s Uco(� s ►rso(�xQ. <br /> Inspection Form Included:0 <br /> Comments Included:0 Xf^k <br /> Business Rep's Signature Phone Number Ins c or's Sig r alure Phone Number <br /> INSTRUCTIONS ON BACK r �� �� a E /y Mt 1 62081 <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy.LFA <br /> 0615104.0487 <br />