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4E- Waste Tire Survey'&Inspection Report Inspection Report Number ■ <br /> StateCalifornia Survey Form - Page 1 1 5 - 1 0 0 6 3 7 1 <br /> CIWMB 181(New 04104) <br /> Calatxnla Integrated ed Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type(Fill one) <br /> Site Suffix: . q 2 c pry <br /> _ ? � ' Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �aXIS. O 0. N Q CHP Q CIWMB Q Complaint Q Educational Visit <br /> Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Phy `\L <br /> sicalddress <br /> Inspection Date J 42 � \ ( / v <br /> ITime In Time Out <br /> BusinessRepp j TitleO AM _ Q AM <br /> 0 '?— : 5_ S ®PM c> Z 5 40 PM <br /> Operational Status Tire Type Business Role Storage Type- <br /> Tire Count(W hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fin all that apply) <br /> •Active ®Passenger 0 Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive p Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill.all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ®Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q 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 f az a <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 <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB wad j ` <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs Within 90.days a, <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q . 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers >: f <br /> Q Q 14.CCR§18461-Manifest System.Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § t A r <br /> Comments <br /> — <br /> .� <br /> Inspection FormIncluded:.Q <br /> Comments Included:Q `ABusinep's Signature Phone Number InsolectoeiSionature` Phone Number <br /> INSTRUCTIONS ON BACK ,ty P I 62081' <br /> ■ <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LPA ® �■ <br /> 0529204. 1052 <br />