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a <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stateof1 California <br /> ) Survey Form - Page 1 i 4 ~ 1 01 4 76 1 <br /> CIWMB 181 Naw 04!04 <br /> california Integrated Waste Management Board <br /> PartA- Survey _ - BLUE ORBLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: © l0 �j fj 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected 8 <br /> P Y Inspector <br /> Phys cal dr ss ! r S <br /> q Inspection Date t) / I -2 5- <br /> Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> 0P QPM <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) I (Fill all that apply) <br /> 0 Active 10 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> � 0 Inactive 0 Truck <br /> Longitude .- 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other <br /> Jf N+( <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility us <br /> 0 0 PRC§42951 Waste Tire Hauler Registration and Transport of Tires y3` <br /> 0 0 <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle "0 <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements j <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 <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> •'�ri � rte'=�'__ -_- _ =i= <br /> 0 0 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 <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § _ <br /> Comments (FR-2- Aye Kt.;'4- C41z- .14- C <br /> IS <br /> 4'r-e-5 WAatAn'� C7r q►`e' � V-Ck'm%4j <br /> Inspection Form Included: 0 <br /> Comments Included: 0 +� <br /> — - - I4Busines, ep' Signature Phone[Number 1or's gnat Phone Number <br /> INSTRUCTIONS ON BACK A , P L 2' 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />