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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of CIWNIBCalfor Survey Form - Page 1 19 - 1 0106 7 4 <br /> CIWMB 187 stew nago <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details ---_ <br /> TPID- I (I -� - ` Inspection Type (Fill one) <br /> Site Suffix: I@ Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ / If Referral,choose referral type(Fill one) <br /> Identifier: Cif w'7� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name � Inspected By Inspector <br /> T t _ o Frage <br /> Physical Address <br /> Lr�/ _ n Inspection Date O y- I Or 4 odes C ����`/ Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> V OF O PM O PM <br /> (((JJJ erational 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 f 0 Active Q Passenger !Generator O Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive •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 0 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 /> 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§16459.1(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 <br /> Q Q Other: § J }� G iI (� <br /> Comments ,,, �„-_ i,„�a�/ _ 1!_ Pa t-L <br /> -Ar <br /> rtfl.rkod SPflsa. <br /> V�, � nest-s ;�iwd M <br /> i&sass d.. 'Vo_ _r D <br /> Inspection Form Included:Q <br /> Comments Included: - - <br /> Business Re s Si,natur Phone Number Ictor's n ure Phone Number <br /> INSTRUCTIONS ON BACK IENXIRIMALJEJ 111,213162081 <br /> ■ 0716504.0017 White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />