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Waste Tire Survey & inspection Report Inspection Report Number . <br /> Stale of California <br /> Cgrated asteManage Survey Form - Page 1 i 9 - 1 4 2 5 81 3 <br /> Call}ornla Integrated Waste Management Board <br /> Part_A-Survey BLUE OR BLACK INK PEN <br /> Business Profile iInspGCtlon Details <br /> TPID- r Inspection Type (Fill one) <br /> Site Suffix: ` 1 p ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> ( Inspected By Inspector <br /> �( <br /> Physlca Adro � <br /> Inspection Date b !J I C> <br /> Time In 'C Time Out <br /> Business Rep Titlelt� Q AM Q AM <br /> 0 PM O PM <br /> pow ���So►� 5��,ry tSo�/ <br /> Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply} <br /> f ® Active ® Passenger e Generator *Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — O Planned Q OTR O Fnd-Use Q Container <br /> I I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Coliectioll Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORi»MENT.&'LATUS <br /> °,;A=. FtAtlLINQ Attll .MAiAIIPET;:R�QIJIRMEN T. <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O NatlaQ Of ttlolatlgn: Q Extension <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. COMP111dtlC8,Of38dilne. <br /> O O PRC§42956-Registration/Decal in Vehicle m <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O <br /> 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required io1 NQVl or EXT) <br /> O O 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 HaulersO R9ieriflt€ GiWW 5: liforcement 1 <br /> O 014 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ". <br /> •n— , <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .i <br /> O : O !Other: § <br /> Comments -+ <br /> Inspection Form Included: o f <br /> Comments Included: 1' �� <br /> Business Rep's Signature Phone Number Inspec Zr".Signatu Phone Number <br /> INSTRUCTIONS ON BACK °� rrf,#Ct`r� t1G�4v1r LC + �I�'J�iP ,L? � 62081 er <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />