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Ctrl Waste Tire Survey & Inspection Ins Report Inspection Report Number <br /> state P P <br /> CIWMB 7a1(Hew a 0 <br /> W04) Survey Form - Page 1 12 - 1 0 1 3 54 7 <br /> CIwM <br /> CaliforniaaliIntegrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection- O Inspection Type (Fill one) <br /> Site Suffix: ( ®Routine Q Re-inspection O Referral O Observation <br /> LocalLocal If Referral,choose referral type(Fill one) <br /> er: �� �N 0 CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r Inspected By Inspector <br /> Ph slcal Address <br /> L.i r - <br /> �� Inspection Date © 2 / Q -7 <br /> l <br /> , Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 0P 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 /> f f ®Active Passenger 0 Generator O Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D Q Inactive O Truck <br /> Longitude - 0 Planned 0 OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture O Shredder ®Other ah Fle.- J^ <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility I <br /> OO <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts With Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O i O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB t <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 010 Other: § <br /> Comments 1 "IGCb �'� S Q rj[ ! l9ii ��i 5 Wa. u f <br /> �r'�w� � 5_I_�%— ��h--O.fC�ti Li TLc�n.�_ �-LJr� � t.i.✓wTL� � __.Inspection Form Included:Q <br /> Comments Included:Q,- 2�f -W-07q7 <br /> Busines ep s Signature Phone Number Ins_ ksSignature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIE 1 2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0708104.0038 <br />