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Waste Tire Survey & Inspection Report Inspection Report NumberStat ■ <br /> COGNIB California Survey Form Page 1 f 6 - 1 4 4 8 0 5 <br /> CIWMB 181(New nage <br /> California4104) <br /> Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile `,nspectlon Detalls <br /> TPID- + S , _ Inspection Type (Fill one) <br /> Site Suffix: <br /> 0 Routine Q Re-inspection Q Referral 0 Observation <br /> Local j� If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP 0 CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name <br /> ff inspected By Inspector <br /> P ysical A dress <br /> 3Bz/ 74_44e�ti/1 A. <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> IJ O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) A (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)I <br /> Active 0 Passenger Q Generator 0 Outdoor <br /> � Q closed 0 Altered I <br /> Latitude <br /> GPS 0 Hauler 0 Indoor <br /> 0 Q Inactive � Q Truck <br /> Longitude — Q End-Use 0Container <br /> Planned O OTR <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer (:)Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body 0 Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Hauler O Agriculture 0 Shredder O Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility I@ &M&T STATUG <br /> r lAt ' <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 /> � r <br /> 14 CCR§18459 -Responsible Entitles Complying with Manifesting Requirements <br /> O 0 14 CCR§ 18459.1 a b c -Tire Program ID Number from CIWMB ' :„ I <br /> 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 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 Facilitiesk <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § <br /> Comments �'S / L f" �O i'► was ��S <br /> SQ� ,,•��T h Uc�?f� `���j'a9��S5 cc�t �- �e- o.. �� �R u�� <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Ignatu Phone Number <br /> - ;,� <br /> INSTRUCTIONS ON BACK - +� rtfl P L E 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />