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Waste Tire Survey & Inspection Report Inspection Report NumberStat ■ <br /> ClW California Survey Form - Page 1 16 - 1 Q 5 6 6 <br /> CIWMB 181 INew 04704) <br /> Callfornla Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Deta{Is <br /> TPID- r Inspection Type (Fill one) <br /> Site Suffix: © V 1 —7 If 6 D • Routine Q Re-inspection Q Referral Q Observation <br /> Local tom- If Referral,choose referral type(Fill one) <br /> Identifier: f� � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility-Name ' 7Y Inspected By Inspector <br /> Physical Address <br /> S <br /> Inspection Date 1 0 / C) Lf <br /> Time In Time Out f <br /> Business Rep Title O AM Q AM <br /> O PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) I <br /> 0 Active ® Passenger i Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 /> .AN, T I TATU& <br /> _ SQ � � 8TR��WR�M�NT�- l � <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q N olatl n Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C4>4 q xdli.ii <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements _" I I m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB w <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days 1 NOV o(QfT] <br /> I <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 HaulersY �( �gjtt► #fT1�p*: r I! <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ,Other: <br /> Comments <br /> use <br /> Inspection Form Included: Q: <br /> Comments Included: Q R` ra <br /> _ - -2g X� <br /> Busisep�sSignature <br /> Phone Number In is Signature Phone Number <br /> INSTRUCTIONS ON BACK � "iiF, }#f `f' JiX � )C A", LI, <br /> y Z 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />