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«, Waste Tire Survey & Inspection Report <br />r State of CalHornia <br />CIWMB 18asteManag) Survey Form Page 1 <br />Calrfornla Integrated Waste Management Board <br />Part A. <br />Surve _ <br />Business Profile _ Inspection Details <br />Inspection Report Number <br />i Z-1013191 <br />BLUE OR BLACK IN <br />N <br />PEN <br />TPID - Inspectlon Type (Fill one) <br />Site suflibc l ,j S S <br />0 Routine Q Re -inspection Q Referral Q Observation <br />LocalIf Referral, choose referral type (Fill one) <br />Identifier: 1"' �,tz�.7� ��� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name _ (� Inspected B <br />P y Inspector <br />Physical Address <br />Business Rep <br />%%�� <br />/ " 4e /cJlc .f <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Q Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />Title n� " <br />3 <br />Inspection Date <br />Time In <br />0 y / / -2- / o 7 <br />Time Out <br />0 A 0 A <br />' QPM 0 P <br />Operational Status <br />TireTypeBusiness <br />Rote Storage Type <br />6 <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) ill all that apply) <br />Q <br />Active <br />® Passenger <br />• Generator 0 Outdoor <br />O <br />Q Closed <br />Q Altered <br />Q <br />Q <br />Q Inactive <br />Q Truck <br />Q Hauler Q Indoor <br />O <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />l <br />Q <br />Q <br />Q Planned <br />Q OTR <br />Q End -Use Q Container <br />Q <br />14 CCR § 18460.2 -Manifest System Requirements for Registered Waste Tire Haulers <br />•'..i; <br />Q Trucking Fleet Q Government Q Retreader Dismantler Q Tire Derived Fuel <br />Q Car Dealer Q Collection Q Crumb Rubber <br />Q Agriculture Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />Inspection Form Included: Q <br />Comments Included: Q <br />Business Rep's Signal <br />INSTRUCTIONS ON BACK <br />■ <br />White Copy: CIWMB <br />0711604.0142 <br />Phone Number,,Inspctor's Slenature Phone Number <br />I c 1 AS M P .L E 11 [21 3 6208, <br />Yellow Copy: Operator Pink Copy LEA ® ■ <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />l <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />! <br />Q <br />Q <br />14 CCR § 18460.2 -Manifest System Requirements for Registered Waste Tire Haulers <br />•'..i; <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q_ <br />0 <br />Other: § <br />Comments <br />Inspection Form Included: Q <br />Comments Included: Q <br />Business Rep's Signal <br />INSTRUCTIONS ON BACK <br />■ <br />White Copy: CIWMB <br />0711604.0142 <br />Phone Number,,Inspctor's Slenature Phone Number <br />I c 1 AS M P .L E 11 [21 3 6208, <br />Yellow Copy: Operator Pink Copy LEA ® ■ <br />