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i <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWMB <br /> of 81(Now ) Survey Form - Page 1 1 3 - 0 14 7 6 5 <br /> clwMe�ftt New ga"aa <br /> California Integrated Waste Management Board <br /> I' <br /> art <br /> A_- Survey BLUE OR BLACK INK PEN <br /> Business Profile - IlInspection Details - - <br /> TPID- Inspection Type (Fill one) <br /> 1 Site Suffix: c) -7 ® Routine Q Re-inspectio Q Referral Q Observation <br /> Local If Referral,choose referral type Fill one) <br /> Identifier: ��•.�f�t� �y Q CHP Q CIWMB Q C mplaint Q Educational Visit Q Other <br /> l Business or Facility Name / Inspected By Inspector <br /> Physical Address <br /> ¢- <br /> Inspection Date a� / Q -3 <br /> Time Out <br /> Business Rep Title Time In 0 AM 0 AM <br /> 0 M O PM <br /> Operational Status Tire Type 1 Business Role � Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passe iger Q Generator Q Outdoor <br /> O Q Closed Q Altera <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q inactive Q Truck <br /> Longitude — Q Planned Q OTR ® End-Use Q Container <br /> � I l <br /> Business Type (Fill all that apply) j <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 10 Dismantler Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other � �,,r <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> FMO k :$V4Tt1S <br /> _ , ' .✓i�/ /jam/%i/,. ./..i/,. �!: i -. <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ; tlifa( �n Q story_ <br /> Q O I PRC§42953-Contracts with Registered Waste Tire Haulers. + <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entitles Complying with Manifesting Requirements I <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q <br /> QQ . 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> IIII <br /> Q f Q 14 CCR§18459.3-Retention of Manliest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Harders ' <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ aF <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments ' ;l 7l-a W 1 ll "se- —2 `�!!^�► C..+`f�� '�Int'S I�,/ ,r GlS p`^r -- (o i, <br /> 4 <br /> pQt.�tr �la^ s 'TeP�ckS jG• l rc. GLIr/�� t3� C�i�7�„v�c�Y/ <br /> ---1�" x_-Prr�-di.-r -s i <br /> Inspection Form Included: Q <br /> — �iU- - - i - - — - <br /> Comments Included:Q - - — <br /> Business Rep's Signature Ph ne Number In gnature Phone Number <br /> INSTRUCTIONS ON BACK ` -: R L (r 2 3 <br /> While Copy:CIWMB Yellow Copy.Operator Pink Copy:LEP <br /> f <br />