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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> Crater 181(Nrnia 4 - 1 0 1 0 8 2 7 <br /> CIWMB 181 <br /> eManag) Survey Form - Page 1 I <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / D o y Inspection Type(Fill one) <br /> Site Suffix: A 7 p IS Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. sQR C/O Al CHP CIWM13 Complaint�' � � � P Q Educational Visit Q Other <br /> Business or Facility Name — - — -- <br /> Lp/p Inspected BY Inspector <br /> /� <br /> Physical Address <br /> 6-05' /I/a? /D,- <br /> J7 <br /> (S-/_e � 9S ^� Inspection Date <br /> � of ov Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 30 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ° 0 Active O Passenger t'Generator 0 Outdoor <br /> Closed O Altered <br /> GPS Latitude O O Cl0 Hauler Q Indoor <br /> O O Inactive Truck <br /> Longitude _ OPlanned O OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Government O Retreader O Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 'J <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § <br /> Commends <br /> %.:ti <br /> Inspection Form Include*B..Iness <br /> Comments IncludeRep's Signature Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK 62081 <br /> EXatMP �. E ! z� -- <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA © ■ <br /> 0724204.0385 <br />