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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Staten California Survey Form - Page 1 i 1 - 1 0 1 3 1 9 0 <br /> CJWMB 181(New 04) <br /> CaliforniaaIntegrated Waste Management Board <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / / - D / Inspection Type (Fill one) <br /> Site Suffix: O 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQA z'r" 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Busine/s�or Facility Name Inspected By Inspector <br /> � <br /> er <br /> Physical Address J 9 1 0 <br /> g rInspection Date D / <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> t4 et A 0 PM 0 PM <br /> Ql�l <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / J (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ` / 0 Active 0 Passenger •Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § <br /> Comments .�p� ccsf L20�zy ati.rto � � i� cr/� <br /> ee-� <br /> Inspection Form Included: <br /> Comments Included:0 Ines;Rep's SI@WurePhone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK �� p E 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0711604.0112 <br />