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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateof <br /> 181(New 04104)California <br /> CIWMB Survey Form - Page 1 i 8 - 1 0 1 3 1 3 1 <br /> Califomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Sualneas Profile Inspection Detalls <br /> TPID- Q [� �� - / Inspection Type (Fill one) - — - <br /> Site Suffix: 1 ! 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: _ pL 0 CHP 0 CIWMB 0 Complaint Q Educational Visit 0 Other <br /> Business or Facility Name <br /> G�P Inspected BY Inspector <br /> 'Physical Address <br /> G� Inspection Date <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> C� Q PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) 6 Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r Active Passenger® � g ®Generator ®Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (FIR all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet ®Government Retreader 0 Dismantler Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 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§16459.1(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 Other. § ` A <br /> Commertts /�tw � ��Cb...- ^— _/�'eC/2 ���[a2— I v/.t rn:•�{--. <br /> exo4— 4itL4,04,4e- "Te'r rewlej <br /> Inspection Form Included:O <br /> Comments Included:0- — - - <br /> IBusiness • Si nature Phone Number. Ins ctoe ature <br /> one Number , <br /> ■ INSTRUCTIONS ON BACK JEJXJAJ ILIE1i 362081 <br /> White Copy.CIWMB Yellow Copy.Operator- Pink Copy LEA ® ■ <br /> 0"116.04.0117 <br />