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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> Cgrated 1(NeManag) Survey Form - Page 1 i 9 - 1 01 4 7 2 5 <br /> California Integrated Waste Management Board <br /> Part A. Survey BLUE OR BLACK INK PEN <br /> Business Profile 1 Inspection Details <br /> TPID- inspection d Q I Ipection 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: �q��t,� �h,-�-� Q CHP Q CIW(vfB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ler- <br /> Phytical Address <br /> � A Inspection Date 09 I 2-0 <br /> Time In Time Out �CC <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)I (Fill all that apply) (Fill all that apply) <br /> f Q Active Q Passenger Q Generator Q Outdoor <br /> 0 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned Q 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 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility f.EMR0kc-.0m <br /> iV l .A I HAULING 1lND.MA (FEST REQUIREMENTS 1 O Natic#DfAlfaaln � {. <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q I Q PRC§42953-Contracts with Registered Waste Tire Haulers. C0ttlpli #CIE< I ,�' i <br /> O Q PRC§42956-Registration/Decal in Vehicle `' <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Do, <br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q l Q <br /> O I O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers yr,- <br /> 14 CCR§ 18461 -Manliest System Requirements for Waste Tire End-Use Facilities <br /> //.r/i <br /> Q Q /f// ti r j/ <br /> �� 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (`�� . •. f�,�/�ic %gip �; j�j <br /> Other: § <br /> O O / L)� <br /> Comments <br /> Inspection Form Included: Q1 <br /> Comments Included: Q – — �0 - <br /> Business Rep's Signature Phone Number actor's i ature Phone Number <br /> o <br /> INSTRUCTIONS ON BACK �OnIT iii# l` ,� K� X A M P lr E � � � 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br />