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Waste Tire Survey & inspection Report Inspection.Report.NumberState . <br /> CWMB California Survey Form - Pagel16 - 1014846 <br /> CIWMa1 a(teManag4) <br /> California Integrated Waste Management Board <br /> Part A- <br /> SU <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID Inspection Type (Fill one) <br /> Site Suffix: l 0 , ®Routine Q Re-inspection Q Referral Q Obseryation <br /> Local r-, If Referral,choose referral type.(Fill one) <br /> Identifier: 0k'V'- o�� t� C'0 n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ((( <br /> Inspected.By Inspector <br /> Physical Address 3 <br /> .�+ Inspection Date <br /> � 1 S*.Fh <br /> Time In Time Out <br /> Business Rep Title o O AM O AM <br /> ®PM 0 Z- Z. ®PM <br /> -- — Operational Status Tire Type Business Role Storage Type <br /> TireCount(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger ®Generator ®Outdoor . <br /> O Q 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 f <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other �fdM ILL, <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires s t <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0. PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c):Tire Program ID Number from CIW MB s=' <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 a , <br /> Q Q 14 CCR.§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§,18462-Manifest.System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments �� <br /> S 4INA� to.c' 1 tr�h^1 ,T wu t <br /> L.mSl wu�1.� t w-0'_ ? L61 L-5 C Wf_s - _Lwks <br /> COXAIwt t t,k'o vU.u.W.v _6, r V U b`o av =KI1 <br /> Inspectlon Form Included:Q <br /> 9c�� <br /> Comments,Included;Q <br /> Busi ss Rep's Signature Phone Number In pector's Signature phone Number <br /> ,�• <br /> INSTRUCTIONS ON BACK j A'M P['L Ej 111213 62081' <br /> ■ - <br /> White Copy:CIWMB, Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0529204. 1061 <br />