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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rr Stale of California <br /> Cgw too t tN Maage - Survey Form,--Page 1 1 8 - 1 0 0 6 4 9 8 <br /> California biteg2leo Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile. [Inspection DetalIs <br /> TPID- -3 - 0 1 Inspection Type (Fill one) <br /> Site Suffix: . 0 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 /> Physical 3ddress d <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Titlel O , 4 8 O AM O AM.I l a PM O PM <br /> Operational Status TireType Business Role Storage Type <br /> Tire Count(Whole IPTE) 0. {Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ®Active Q Passenger ®'Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> C7PS Latitude Q Hauler Q Indoor <br /> o Q Inactive 0 Truck <br /> Longitude - 0 Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q 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 Q Other <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility n <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953.Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decalin Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB sy <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest.Forms and Tire Trip Logs within 90 days <br /> O Q 14 CCR§18469.3-Retention of Manifest Forms and Tire Trip Logs for 3 years r✓ � , <br /> Q ,Q .14 CCR§18460.2 r Manifest System Requirements for Registered Waste Tire Haulers <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 jtyxf w� � <br /> O O <br /> Other: § <br /> comments -Se-- �a t� �. t ifs 1� (p1 �_- <br /> ` 1 vc. r'A-1 �e.d�d� ale` �r�n.aar <br /> jr <br /> Lj <br /> k Entered <br /> a <br /> Inspection Form Included:Q <br /> Comments Included:Q , 'e <br /> �09�- 53 76 <br /> Business Rep's Signature Phone Number Ins re,. Phone Number" <br /> INSTRUCTIONS ON BACK M p L E 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br /> 0529204.1189 <br />