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= , Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California Survey Form Page 1 i 9 - 1 01 3 5 7 <br /> CIW187(New 04104) <br /> CalNornia IntegraMBted Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: 9 9 7 s O ;Routine Q Re-inspection Q Referral Q Observation <br /> Local /�" / If Referral,choose referral type(Fill one) <br /> Identifier: �OQyu�{t p4c+7T■ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name B Inspected By Inspector <br /> Physical Address <br /> Inspection Date 0 / / 3 U <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> (�c Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Active Q Passenger Q Generator Q Outdoor <br /> 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 <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 <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires a: M <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q 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 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 /> 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 y (" <br /> Q Q Other: § <br /> Comments �+2 �" �� �t� � i2ca Ae. 7 <br /> `y�[pr� � /�L2G'I��i Ily !J° �GK-�+•e ,�lt2f' /VD ��"� ttJ4!'r� �-�--e/L <br /> Inspection Form Included:Q n <br /> Comments Included: <br /> Q <br /> Business_ Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK ) E XC MjP L E I M3 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LFA, ® ■ <br />