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u� Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateof81(ornla Survey Form - Page 1 1 9 - 1 0 1 3 6 2 8 <br /> CIW t*1gt(New..ga <br /> caMomla 4104) <br /> Integrated WasU Menagament Board <br /> Part A-Survey <br /> _ BLUE OR BLACK INK PEN <br /> (Business Profile _ _ Inspection Details <br /> Business <br /> p Inspection Type (Fill one) <br /> Site Sp Suffix: >/ 3 y 0 0A 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 ^ Inspected By Inspector <br /> in <br /> Physical Address <br /> Inspection Date <br /> 9s3�v <br /> P Time In Time Out <br /> Business Rep Title /, Q 0AM D J AM <br /> [l 9 7 ( QPM / 7 0P <br /> — Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) r S <br /> 0 Active Q Passenger Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) L _ <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader p 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 /> J <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q 1 Q 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 Forms 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 Fa°�ei �J Qw 94le- 4,W4 'Aig-e t LC-Oe< <br /> / td /44� adlcra�e." �-fie Poach tee <br /> Inspection Included:Q <br /> Comments Included:Q- r6 <br /> _ 1 Bush Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON CK jEjXIAjMIPjJ_IEj 111213 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA �� ■ <br /> 0619404.0041 <br />