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aWaste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181 thew 04104) Survey Form - Page 1 1 7 10 1 3 6 5 9 <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: _ •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(1�jLGt�l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �— Inspected B <br /> �� �/L"`"' P Y Inspector <br /> Physical Address �' <br /> kw <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep / Title AM AM <br /> o PM (� - 6' o PM <br /> Operational Status Tire Type Business Role Storage Type <br /> ,r( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f r /f(/ <br /> •Active Q Passenger •Generator Q Outdoor <br /> GPS LatitudQ Closed Q Altered <br /> Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) -- <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler <br /> 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 lb Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFQRCEM>~NT'STAT#i5' <br /> V A MAULING AND MANIFEST REQUIREMENTS <br /> --- __ 0 Notice Of Vipipt,ion (� <br /> xtensiort <br /> 0_ PRC§42951-Wasle,Tire Hauler Registration and Transport ull Tres <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. i <br /> Q Q PRC§42956-Registration/Decal in Vehicle Compliance Deadline <br /> Q Q '14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 1 I <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 <br /> 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 /> Q C) Other: § <br /> Comments <br /> Inspection Form Included /r-- S ' V r r/ p <br /> Comments Included: {/ ''�/ "'� _ f' �. Yp 7 w8_03 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK E X A4 dA P L I I c I 1 x2081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0626304.0290 <br />