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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Sate rWMB California Survey Form - Page 1 11 -- 1 0 1 3 0 6 4 <br /> CM1ate 181sNew nage <br /> CMNomla Integrated Waste Management Boerd <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile InspectionUetalls. <br /> l f ! Inspection Type (Fill one) <br /> Site Suffix: 7 0 O ®Routine Q Re-inspection Q Referral Q Observation <br /> Local /t If Referral,choose referral type(Fill one) <br /> Identifier \/�''„` oa. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Buslness or Facility Name <br /> Inspected By Inspector <br /> Physical � � <br /> ress� <br /> 1�g <br /> � C //__ Inspection Date� ���w Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM QPM <br /> R*r-- 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 /> r i 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 hat 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 0 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 NFO1t _XTyh _y <br /> Notice Of Violation Dior <br /> Q 1 O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. 4 t3eatl11 r <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 5 <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 The 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 zF , <br /> Q Q Other: § ° �a1 Frr244" s <br /> Comments AinwLkm <br /> > <br /> w,s�nlQ <br /> U') .ytl e�. ics�c�s nt�r ' r: _ -Iv .6r1 C*_ +-.. 'c�: <br /> — c � <br /> Inspection Form Included:Q ` <br /> Comments Included: LA 0 <br /> slnsas Rep's Slgnature Phone Number gnature Phone Number <br /> INSTRUCTIONS ON BACK r{ 1114 P L E 1[2 131 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0634704.0262 <br />