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Waste Tire Su <br />'t'La�y y &Inspection Report 'nspection Report Number <br />State of California T 1 <br />California lne de <br />grat tWaseManagementBoard Survey Form - Page 1 y y 1141302 <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile ; Inspection Details <br />TPID - / Inspection Type (Fill one) <br />Site Suffix: � –I % Y q ( 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local % 7 If Referral, choose referral type (Fill one) <br />Identifier: SQ+ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name 0 Inspected By <br />Physical Address <br />Business Rep <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude – <br />Business Type (Fill all that apply) <br />Title <br />Inspector <br />,-4!GR-D9�"V) JLOLA <br />1,2dInspection Date j `n Q O 9 <br />/ V <br />E Time In Time Out <br />O 2 � ®AM j �— 0 AM <br />J <br />[� PM <br />O PM <br />0 <br />Operational Status Tire Type <br />Business Role Storage Type <br />0 <br />(Fill one only) (Fill all that apply) <br />(Fill all that apply) (Fill all that apply) <br />0 <br />® Active 0 Passenger <br />40 Generator 0 Outdoor <br />O <br />0 Closed 0 Altered <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />0 <br />0 Hauler 0 indoor <br />0 <br />0 Inactive 0 Truck <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />0 Planned 0 OTR <br />0 End -Use 0 Container <br />I New Tire Dealer 0 Auto Repair U Trucking Fleet U Government U Retreader <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />® 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 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />114 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />Comments Q� -, .j �y ' y c � <br />f fie'."APs Gt�t� L—t A, I-. 7/%� � 11� /e-44zodc <br />Inspection Form Included: 0 <br />Comments Included: 01 Bul <br />INSTRUCTIONS ON B, <br />re j Phone Number <br />Copy: SIV 13\1 Yellow Copy: Operator <br />Dismantler 0 Tire Derived Fuel <br />- '2-0 f <br />led"g. 03-73, <br />Inspector's Signature Phone Number <br />l�f��! 62081 <br />! ` P L T <br />Pink Copy: LEA <br />