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=zo . Waste Tire SL ,ey & Inspection Repoo. Inspection Report Number <br /> Stat" <br /> CIWMB B California I 1 . - 11278 6 3 <br /> Cgrated Waste Management <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Pant A- Survey BLUE OR BLACK INK PEN <br /> .Business Profile Inspection Details <br /> TPID- l Inspection Type (Fill one) <br /> Site Suffix: t y 2 S © ' ® Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _ O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> �_ Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> I <br /> City State ZIP Code Time In Time Out <br /> Business Re li <br /> - <br /> p Title I l J� : La] <br /> � ® AM ( � Q AM <br /> / QPM / o • ® PM <br /> -� � <br /> � - -- <br /> - -- - - Operational Status Tire Type. Business Role Storage Type <br /> The Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ® Active tO Passenger ® Generator ® Outdoor <br /> � I O Closed O Altered <br /> Latitude <br /> GPS i �J •,_�__ -�—JO Hauler ® Indoor <br /> O Inactive ® Truck <br /> Longitude - I I i i O Planned O OTR O End-Use O Container <br /> i I I •! I I 1 I __ __ _ <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer O Auto Repair ® 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 0-Hauler O Agriculture O Shredder O Other i I <br /> Part B- Inspection of Waste Tire.Dealer, Generator, Haulerand End-Use Facility TSTATUS � �� <br /> UL <br /> HAING AND MANIFEST�REQUIREMENTS`�_, � � ' '�' ���s A 4 <br /> .,� <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires : <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance;Deadline =�:�+ �•�.��a <br /> O O <br /> PRC§42956-Registration/Decal in Vehicle ,�, <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements pate! w �, <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days44 <br /> s(Riqu d.forfV0lorEXT) <br /> m wsyex r. �gar s.a .q•"c <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs fora years <br /> O O - 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire HaulersQRefer►ed t CtwMB" yEnforceme tt <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use FacilitiesO O <br /> 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators »� ., <br /> O O ® mplianceoViolatlont <br /> Other: § `" ' <br /> Comments <br /> -- <br /> Inspection Form Included: O <br /> Comments Included: ® — — --- <br /> Busine s Rep's Signature Phone Number Inspector's Signature Phone Number <br /> � ��•�, �� 62081 <br /> INSTRUCTIONS ON BACK :Corr c correct° �' � E X AIM P L1� 2 :3 <br /> White Copy: IW B Yellow Copy:Operator Pink Copy:LEA <br />