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■ t Waste Tire Survey $ Inspection Report Inspection Report NumberState-, ■ <br /> CIWMB1'I"°r°I° Survey Form - Page 1 1 6 - 1 0 1 3 3 6 9 <br /> CIWMB 187(Naw n g- <br /> CalHomla Imegrabd W.M.Managamant Board <br /> Part A Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 7 - O Inspection Type (Fill one) <br /> Site Suffix: 2 •Routine Q Re-inspection Q Referral Q Observation <br /> LocalC�� If Referral,choose referral type(Fill one) <br /> Identifier: G IJ, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> rnr Mrr— tn—,y <br /> Business or Facility Name <br /> Pi.1Inspected By InspectorPhyAddress <br /> �^ '52,c> <br /> '"MS Inspection Date O pb <br /> C/�t !� Time In Time Out <br /> Business Rep Title d Q AM O AM <br /> i p c <br /> FAN' *PM O PM <br /> Tit I �c Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' 1 1 S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L4 40 Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ®Hauler ®Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government ®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 Facility <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 10 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: § p <br /> Comments ► L 1_ 77Z5 a,.-- �� Jh �t �i l4- 9.cX <br /> (�.sfvwS oiv�2. w1a.�l�r-s^ b,_„ <br /> Inspection Form Included: <br /> Comments Included:Q Q Busin — ature <br /> gr �� <br /> Phone Number Ins tors Signature Phone Number <br /> INSTRUCTIONS ON BACK rA IMI P 'L 2 g 62081 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy LFA ■ <br /> 0605204.0542 <br />