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Waste Tire Survey & Inspection Report Inspection ReportNumber ■ <br /> Sta llfomla Survey Form - Page 1 1 1 - 1 01 3 4 4 7 <br /> CgVMBMB 18 1B1(Naw a g <br /> CalHomia Integrated Waste Manaagee <br /> ment Board <br /> Part A-Survey _ BLUE OR BLACK INK PE_N <br /> Business Profile Inspection Details <br /> TPID- y �J' 7r " _ o / Inspection Type (Fill one) <br /> Site Su <br /> 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local (' n If Referral,choose referral type(Fill one) <br /> Identifier: ezy OR !, C...E Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 <br /> 3 7 - <br /> I ` <br /> Inspection Date <br /> Time In Time Out f` <br /> Business Rep Title 0 Am 0 AM <br /> / q ; ,�� 0 PM / -3 'T © 0 PM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> , r <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 Q Auto Body 0 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 <br /> 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 <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <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 Fortes and Tire Trip Logs for 3 years <br /> Q 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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments Au-:14;-La ikf AS d Qum )Z4< f� <br /> �P..s �Pl�e �lQe.�,;_"�4,y� yr'Qrwca� ���-0-7 _ �"���'J�, ���r,°X• <br /> _� LlJ'��/�e��sdr-PSC o'�i!"�1 OK �i T4. /!/d l�iv-t�g���Gs�-1'• <br /> Inspection Form Included:Q <br /> Comments Included:Q .. <br /> Business Rep's SignatuA S,W)42— <br /> re Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK X a M P L E1 11! 62081 <br /> ■ White Copy:CIWM6 Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0615104.0481 <br />