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Waste Tire Survey & Inspection Report Inspection ReportNumber ■ <br />ShtaNTIa Survey Form -Page 1 1 4 -1 41 339 <br />CIWMBB181181 ( (Naw <br />California Integrated Waste Managnag <br />ement Board <br />Part A - Survey BLU_ E OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID- Xr Inspection Type (Fill one) <br />Site Suffix: D ID Routine 0 Re -inspection 0 Referral 0 Observation <br />LocalIf Referral, choose referral type (Fill one) <br />Identifier: "A_ `cN,J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name Inspected By Inspector <br />Phyydifal Address <br />5 4— <br />Business Rep %� Title <br />Cnf <br />Ar -)n as =- <br />Tire Count (Whole/PTE) t <br />GPS Larnuae <br />O 0 Inactive ®Truck <br />Longitude - i Planned 0 OTR <br />Business Type (Fill all that apply) <br />New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler <br />Used Tire Dealer O Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />O Service Station 0 Hauler O Agriculture 0 Shredder • Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />1 3 / o b <br />Time Out <br />0 AM <br />0 PM <br />Business Role to <br />Type <br />(Fill all that apply) (Fill all that apply) <br />® Generator 0 Outdoor <br />0 Hauler 10 Indoor <br />O End -Use 10 Container <br />O O PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O O PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O O PRC § 42956 - Registration/Decal in Vehicle <br />O O 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O O 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />O O 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q O 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />O O 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O O 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O O 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n n Other: § <br />Q Tire Derived Fuel <br />Comments ►�7U(5; ky:1 17-nCA,�ly <br />Inspection Form Included: 0 <br />Comments Included: 0 -�~ <br />mess Rep's Signature Phone Number Ins s Sit <br />INSTRUCTIONS ON BACK FE1X1AIMI R 11 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />0609004.0005 <br />62081 <br />® ■ <br />3� !a� <br />�j ! <br />t ��7 <br />Inspection Date <br />Time In <br />V <br />0 AM <br />• <br />0 PM <br />- <br />Operational Status <br />Tire Type <br />t <br />(Fill one only) <br />Active <br />(Fill all that apply <br />® Passenger <br />O <br />0 Closed <br />0 Altered <br />GPS Larnuae <br />O 0 Inactive ®Truck <br />Longitude - i Planned 0 OTR <br />Business Type (Fill all that apply) <br />New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler <br />Used Tire Dealer O Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />O Service Station 0 Hauler O Agriculture 0 Shredder • Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />1 3 / o b <br />Time Out <br />0 AM <br />0 PM <br />Business Role to <br />Type <br />(Fill all that apply) (Fill all that apply) <br />® Generator 0 Outdoor <br />0 Hauler 10 Indoor <br />O End -Use 10 Container <br />O O PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O O PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O O PRC § 42956 - Registration/Decal in Vehicle <br />O O 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O O 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />O O 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q O 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />O O 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O O 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O O 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n n Other: § <br />Q Tire Derived Fuel <br />Comments ►�7U(5; ky:1 17-nCA,�ly <br />Inspection Form Included: 0 <br />Comments Included: 0 -�~ <br />mess Rep's Signature Phone Number Ins s Sit <br />INSTRUCTIONS ON BACK FE1X1AIMI R 11 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />0609004.0005 <br />62081 <br />® ■ <br />