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■ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateof California t <br /> Cll 1steMgage) Survey Form - Page 1 I+ ---!VVVs\\\ <br /> California Integrated Waste Management Board <br /> PartA-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID• ^ J O - O Inspection Type (Fill one) <br /> Site Suffix: -JL C) 0 Routine 0 Reinspection 0 Referral 0 Observation ' <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -f 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected BY Inspector <br /> Phys Address <br /> Inspection Date � 3 / Z ? <br /> Time In Time Out b <br /> Business Rep Title 0 AM 0 AM <br /> IT0 PM 0 PM <br /> �'-.-S` 111a� <br /> Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 5" (Fill one only) (Fill all that apply) (FIII all that apply) (Fill all that apply) <br /> t 0 Active 0 Passenger .®Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive *Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 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 0 Other <br /> r zy^ <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 i 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 /> 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 ;W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators . �.t;. <br /> 10 1 0 Other: § <br /> Comments <br /> �^`4 1 rL 1/�Q.tn�S 4�9t nC.S -I—J ` RS-it, +L42" -Pry.-- 41� <br /> Ir-•-"it�sT- <br /> Inspection Form Included:0 <br /> Comments Included: -�I'-�17�/L/ �Signatub <br /> `/p$lZ9 O�+ <br /> siness Rep's Signature Phone Number Inspe Phone Number <br /> INSTRUCTIONS BACK <br /> 111P $ Z 62081 <br /> ■ .p ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br /> 0615104.0567 <br />