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Waste Tire Survey & Inspection Report Inspection Report Numberrtate ■ <br /> ClWM(California Survey Form - Page 1 16 - 1 01 31 0 5 <br /> CIWMB 1a1 stew 04104) <br /> Calffomia Integrated Waste Management Boertl <br /> Part A-Sj;" BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- -^7 O Inspection Type (Fill one) <br /> Site Suffix: f ` - ®Routine Q Re-inspection Q Referral Q Observation <br /> Local �Jo� tilr T 7If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q Educational Visit Q Other <br /> Business or Facility Name / <br /> \�JInspected By Inspector <br /> PhyJal Ad la"'re 7t <br /> L�� Inspection Date <br /> c)SZLto <br /> Time In Time Out <br /> Business Rep Title hdtn%t+� O AM O AM <br /> K-1A O PM O PM <br /> - - - 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 �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 /> ®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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> ME <br /> y d . <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <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 " „r k <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O ":. <br /> 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 <br /> Q Q 1 Other: § <br /> Comments �i/ /_�) i+ / ����� L i f AST <br /> Ar.a� ,� _ ` _L —7.I C <br /> 41:...• <br /> Inspection Form Included:Q <br /> Comments Included:Q —!='�n <br /> Business ep's Signature Phone Number Ins or's Signature : Phone Number <br /> ' 62081 <br /> INSTRUCTIONS ON BACK ). f A IMIPILIE1 11-1213 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0720004.0141 <br />