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ij <br /> Waste Tire Su�ey & Inspection Repor0 Inspection Report Number <br /> StateofCallow Survey Form Page 1 8 - 10 14 8 2 2 <br /> CIWMB 187(Naw nage y �, <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK_ INK PE_ N <br /> Business Profile Inspection Details T <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 7 <br /> �, � 7 � � � � � #Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date 0 Z o <br /> � � �Z Time In Time Out <br /> Business Rep Title O AM Q AM <br /> —O PM O PM <br /> T re T <br /> -\ --- - Operational Status ype Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) ( ill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' t 19 4 Active 0 Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned O OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer ® Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> G7 <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 . % a <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q ® 14 CCR§18459.2.1 -Submigaj otUspifeit Fo m a d Ti e Trip Lags within 90 days <br /> 'r <br /> Q Q 14 CCR§18459.3-Retention o anif t o s nd Ire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O 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: § <br /> Comments _ ^ <br /> v G� t�-�.rc.,l``' /L��j r �► (�v V - lab Sri b.` o(o o c> - - <br /> Inspection Form Included: Q i o <br /> Comments Included: Q <br /> Bu Iness Rep's Signature Phone Number Insp c ar s Signature Phone Number <br /> INSTRUCTIONS ON BACK : X A, p LE �� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />