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,4l"11111411 <br /> m <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r C;WM tI11 Nrala Survey Form - Page 1 1 3 - 1 01 4 70 3 <br /> CIWMa'sB 187 Waste <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> [Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector p <br /> Phys a ass <br /> Vtso5_gj�pL— <br /> Inspection Date u R <br /> Time In l Time Outl <br /> Business Rep Title Q AM Q AM <br /> QPM 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 /> r t ! ® Active Q Passenger Q Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O O Inactive O Truck <br /> Longitude — O Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ® Auto Repair Q Trucking Fleet O Government Q Relreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer ® Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> `A HAULING AND MANIFEST REQUIREMENTS <br /> 0 N4tfcspf YfOffl#IA�t:; <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires - <br /> � �o <br /> 0 0 �'I PRG§42953-Contracts with Registered Waste Tire Haulers. ComPlia[}yw le�drygg /, <br /> 0 I Q PRC§42956 Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements DaSe I / <br /> QQ 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 /> 0 0 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 { R$ <br /> 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities � <br /> 00 <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .� rp- �� /��•���✓ <br /> Other: <br /> Comments <br /> Inspection Form Included: O, -st T—, <br /> Comments Included: Q - - - - - <br /> Business Rep's Sig at hone Number InsItor's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK ( � �i X A:N P L E T I] Ji] 62081 <br /> While Copy MB Yellow Copy Operator Pink Copy:LEA ® ■ <br />