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Waste Tire Su :y & Inspection Report , Inspection Repor Number <br /> State f 81lNfOla Survey Form - Page 1 I 1 - 1141263 <br /> CIWMB 181(New nage Y g <br /> California Integrated Waste Management Board `� <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br /> - - - <br /> TPID- � .2, `� - D � .Inspection Type (Fill one) <br /> Site Suffix: J 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local `C` If Referral,choose referral type(Fill one) <br /> Identifier: ckv � <br /> bCol,�,� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> LI <br /> n Inspection Date`"l 534 0 <br /> Time In Time Out (J <br /> Business Rep CC Title <f AM Q AM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 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 ® Other L,r S {— es <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENPORCEMENTSTATJS <br /> V, HAULING AND MANIFEST.REQUIREMENTS .h <br /> ension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 - <br /> Ext <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle i <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years t iPa <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers t <br /> i <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 § YRequirements <br /> 14 CCR 18462-Manifest System for Tire Dealers or Waste Tire Generators w G > <br /> 0 0 Other: § <br /> ko <br /> Comments <br /> Inspection Form Included: OI <br /> Comments Included: 0 OgtJ�P- - <br /> Busine R 's a Phone Number 41nctor* S' nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON FLACK � BC �� � <br /> ,Vhita Con":CW via Yellow Copy:Operator Pink Copy:LEA � f <br />