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u Waste Tire Survey & Inspection Report Inspection Report Number <br /> BgratedCa�steM Survey Form - Page 1 f 1 - 1 0 1 0 8 0 8 <br /> cIWMB 18,(New 04/04) <br /> CalNomia Integrated Waste Management Board <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection- D / Inspection Type (Fill one) <br /> O 4 <br /> Site Suffix: Y 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �dClYf Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Ad egg 3q <br /> Inspection Date D 0 7 <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> O PM QPM <br /> 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 /> I rlf0 Active 0 Passenger g 0 Generator •Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q 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 /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityIL LAW <br /> t <br /> 4I,r a <br /> Q 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 /> P t <br /> Q O 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 <br /> r/ G— <br /> ut�arf-e 1�P A1 c•--e_p0( <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business ReA,; <br /> re 1.14 Phone Number Inspector's Signature Phone Number <br /> 6IIrr �iu,•I, <br /> ■ INSTRUCTIONS ON BACK IEjXjAjMjP1L1E1 1112I3I 62081 <br /> 0716504.0002 White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA " ■ <br />