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60 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMetst(New M oage) Survey Form - Page 1 1 7 . 1 01 3 3 4 5 <br /> California Intaprarod Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- // Inspection Type (Fill one) <br /> Site Suffix: C t7 g © © p - 0 •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 <br /> Inspected By Inspector <br /> Physical A6dyy ress�� <br /> Inspection Date J / Z O / O S- <br /> ?' Time In !/ Time Out <br /> Business Rep O D f Title O AM l 0 AM <br /> !�J P, 0 PM © Z I B PM <br /> -- Operational 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 /> f r 1 .Active Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> QTrucking Fleet Q Tire Derived Fuel New Tire Dealer Q Auto Repair • Q Q <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O 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 /> O , O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O 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 /> Q 1 Q 1 Other: § <br /> Comments <br /> j e.v e�Q tM....J•�cs� o� /.�-7��yS. ..� �..� I��__ <br /> +Pvs ef, _ f <br /> _ -2, !� ll r•a.. s <br /> Inspection Form Included: Q <br /> Comments Includedr — - - <br /> pBusines p's gnature one Number In p or's Signa re Phone Number <br /> INSTRUCTIONS ON BAC A M P L # ! i 3 62081 <br /> ■ White Copy'.CIWMB Yellow Copy:operator Pink Copy.LEA © ■ <br /> E+6137 104.0 1 69 <br />