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t , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cf=11(N Survey Form - Page 1 I - 1 0 1 3 7 41 <br /> CNVMB 161(New W/O4) <br /> Calitomia Integrated Waste Management Board <br /> Part A—Surve�r BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I ^ - O Inspection Type (Fill one) <br /> Site Suffix: �( ®Routine Q Re-inspection Q Referral Q Observation <br /> Localt If Referral,choose referral type(Fill one) <br /> Identifier: J��h CAOUJ4V O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility NameU <br /> U -- <br /> Inspected By Inspector <br /> 4S4 TI-14-C4 <br /> Physlca Address <br /> 0'Q0 E �Q5 �nv / <br /> -Tra Inspection Date © a I O <br /> Time In Time Out <br /> Business Rep : Title - O *AM Q AM <br /> To e, c^�A 1'1y` O PM I �� O PM <br /> Operational Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /1 (Fill one only) (Fill all that appy) (Fill all that apply) (FII all that,apply) <br /> r VV ®Active 0 Passenger 0 Generator Q Outdoor <br /> Latitude Q Closed O Altered <br /> CIPS Latitude <br /> Q Hauler 0 Indoor <br /> O O Inactive to Truck <br /> Longitude - O Planned Q OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Relreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 O PRC§42956-Registration/Decal In Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 0 1 Other: § <br /> Comments <br /> -Fires i �1J1 Att 7e -fi"'e i �p; b <br /> 49S are k60 R�r <br /> r f r Ora rf of la or(nDo- <br /> Inspection Form Included:Q <br /> Comments Included:Q, - -------- - <br /> Business Rep's Signature Phone Number In or's i nature one Nu r <br /> INSTRUCTIONS ON BACK E F_ [AjMjPJLjEji 62081 <br /> . White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0615104.0563 <br />