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L Waste Tire Survey & Inspection Report Inspection Report Number . <br /> State of California Survey Form - Page 1 i 3 - 1 0 1 3 3 1 <br /> CIWMB 187(New 04/04) <br /> calNornla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' - O ' Inspection Type (Fill one) <br /> Site Suffix: ®Routine O Re-inspection O Referral O Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: ` 61,_/( O CHP O CIWMB O Complalnt O Educational Visit O Other <br /> _ pe Hr`s <br /> Business or Facility Nam <br /> Inspected BY Inspector <br /> Physical Address f <br /> 9sz <br /> .yo Inspection Date O L.{. / C) 6 (� <br /> � I l <br /> Time In Time Out <br /> Business Rep Title O nM O AM <br /> 0P 0P <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) (Fill all that apply) <br /> O Active O Passenger O Generator O Outdoor <br /> Latitude ®Closed O Altered <br /> GPS O Hauler O Indoor <br /> O O Inactive O Truck <br /> Longitude — O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility <br /> NINErc mss, w, - _l ,-.' - �`�' .. ' .• s, -.-�'_ s .. > ` '' 'y - <br /> O `O PRC§42951-Waste Tire Hauler Registration and Transport of Tires b3 <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers, <br /> O O PRC§42956-Registration/Decal in Vehicle y <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days oaf' <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> N <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 0 Other' § j <br /> Comments <br /> Inspection FormIncluded:O <br /> Comments Included:O <br /> Business Rep's Signature Phone Number ^:• or's Signature Phone Number <br /> INSTRUCTIONS ON BACK 10CFAIMIPIL 3 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA <br /> 4_1 r.15 10 4. Pi 7 2 1 <br />