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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> atsleof C�Iorale Survey Form Page 1 1 8 1 0 1 3 1 6 4 <br /> cM1NMB 181 191((New Od104) <br /> c.]'fomfa Integrated Waste Management Board <br /> Part A-Survey_ BLU_E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> SkeSurfbt: O 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: rpm 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit Q Omer <br /> Business or Facility Name (' --.- <br /> Inspected By - - <br /> Inspector <br /> Physical AddreM 3 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> ^^ O PM O PM <br /> Operational Status 71reType Business Role Storage Type <br /> Tire Count(W hole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> r r 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer •Auto Repair 0 Trucking Fleet Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body •Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 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 /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 10 1 Other. § <br /> Comments A" lLdyCPc✓; <br /> �Lk%t°w'i�• � �4� %,Y. qlo /'t.�e�uNe ..�irrayk )L.,"r G'��G'.r l.,"'<..•t� <br /> Inspection Form Included: <br /> Comments Included: <br /> -_Bushy ss R s Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK ® E X A1M P L 2 2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br /> 0708104.0050) <br />