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Waste Tire Survey& Inspection Relbort Inspection Report Number <br /> CIMB 181 e o aState of Califomla <br /> /nl /J� /��t <br /> Caow 04/04)na5 . 1005 ' <br /> lifornia Integrated Waste Ma agement Board Survey Form -- Page ( _ V i V <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business.Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix:, <br /> _J0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local j If Referral,choose referral type(Fill one) <br /> Identifier: _ __ J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> P ysical Address i J - iQ <br /> __! ..i <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title A .r� :j Q AM Q AM <br /> Operational Status Tire T PM Business Rol PM <br /> - ---- -- pe Type a Storage Type <br /> TireCount(Whole/PTE) (Fill one only) (Fill all that apply) (Fillall that apply) (Fill all that apply) <br /> 3� 0 Active 0 Passenger 0 Generator IS Outdoor <br /> O 0 Closed 0 Altered <br /> Latitude <br /> GPS 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR O'End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair (5—Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ®.Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of TiresM <br /> ~ nx <br /> 0 0 PRC§42953.-Contracts with Registered Waste Tire.Haulers. &3 ' <br /> 0 0 PRC§42956-Registration/Decal In Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMBy <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days + <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste.Tire Generators y' <br /> 0 0 Other § <br /> Comments \ 1 <br /> l <br /> Inspection Form Included:0 <br /> -fib6J) 133xla <br /> Comments Included: -- -- - <br /> Bu to - ep's Signature Phone Number nspector' gnat Phone Number <br /> r <br /> INSTRUCTIONS BACKfK ( fir , I 62081 <br /> �� ;, :� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0525804.0147 <br />