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=,e <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stale of Cnlifornia <br /> C8NMB 18ew 04f 4) Survey Form - Page 1 1 3 - 1 01 0 8 2 8 <br /> California Integrated Wastaste Management Board <br /> Part A.Survey_ _- _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details. <br /> - / - O / Inspection Type (Fill o <br /> Site Suffix: <br /> Site ffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �? If Referral,choose referral type(Fill one) <br /> Identifier: JG2/t 01/0 ��-j (aETr y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business oorr Facility Name O a Inspected By Inspector <br /> Physical Address <br /> gal v v <br /> Inspection Date g / ® / Q 7 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 0P 0P <br /> Operational Status Tire Type O Business Role Storage Type <br /> Tire Count(Whole/PTE.) p� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ' 0 Active ®Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive &Truck <br /> Longitude - Q Planned Q OTR Q End-Use •Container <br /> Business Type r(Fill all that apply) -— -- <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader p Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other ^t44 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires x <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements :r <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs Within 90 days <br /> a o <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ' <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ' k j <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r s " <br /> Q Q Other: § _ <br /> Comments �/i �P 4Y a,,o w <br /> /1"P <br /> Inspection Form Included:Q n, <br /> Comments Included:Q " Y� � �vV �����31 <br /> Business R s Signature _ _ Phone Number Inspector's.Signature Phone Number <br /> INSTRUCTIONS ON BACK � E )( A MA P E Z 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ■ <br /> 0723504.0147 <br /> I <br />