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€e Waste Tire Survey & Inspection Report Inspection Report:number <br /> Stateed Califowaste <br /> , Survey Form - Page 1 14 -. 1 4 0 .6 7 4 2 <br /> CIWMB 187 New 04/04 <br /> Callfomle Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspectlon Detalls <br /> TPID- Inspection Type (Fill one) <br /> Sib Suffix: 1 2 3 O 3 - a <br /> 1 ®Routine Q.Re-inspection Q Referral Q Observation- <br /> Local <br /> bservationLel p If Referral,choose referral type(Fill one). <br /> Identifier: q y��D a yt,ci w✓�"f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V 1 <br /> P _Cd <br /> •� Inspected By Inspector <br /> Y Cx �o�S � l — r <br /> Ph si al A dress - >] . 1 � � („u Y-tow <br /> Inspectlon Date O ` S t <br /> Time In Time Out <br /> Business Rep Title Q AM ®AM <br /> C> 2.. a O PM t 0 QPM <br /> �J 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 /> ®Active ®Passenger •Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS LatitudeQ Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 /> .r4'.x aec'z .Y <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility �' ' a�w -� <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires tF <br /> Q Q i PRC§42953-Contracts with Registered Waste Tire Haulers. v ' <br /> Q Q PRC§42956-Registration/Decal in Vehicle '`5`• S' <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements s a <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB h _ <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> - 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers' <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities y 3 4 s <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments <br /> -x� I - 0%A'—Loos'. <br /> tack s-L) wUr-..5, tN v,,\-covr. l` ,-A, <br /> Inspection Form Included:-Qck q^ <br /> Comments Included:Q 14` tt. <br /> liu <br /> NRe . ature Phone Number <br /> 41nsctor's Signature Phone Nurhber' <br /> INSTRUCTIONS ON BACK -, E?X Aft P L E 11121 62081 <br /> ■ W.W.. :Op ® ■ <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA <br /> 0529204. 1051 <br />