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M a <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of gratedCalifornia Survey Form - Page 1 1 3-- 1 41 3 2 4 2 <br /> CIWMB 181(Na.04104) <br /> CalHomla Integrated Waste Management Board <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O / - Inspection Type (Fill one) <br /> Site Suffix: b 41 Routine 0 Re-inspection Q Referral 0 Observation <br /> Local _r, H Referral,choose referral type(Fill one) <br /> Identifier: .Fy Q CHP O CIWMB Q Complaint O Educational Visit Q Other <br /> Busi s or Facility Name <br /> Inspected By Inspector <br /> l� Ste( -s <br /> Physical Address -29 <br /> Cr � Inspection Date <br /> tV Time In Time Out <br /> Business Rep Title O AM O AM <br /> f, O PM O PM <br /> 1 `�� — Operational Status Tire.Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger ®Generator 0 Outdoor <br /> or <br /> Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned 0 OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®Auto Repair O Trucking Fleet O Government O Retreader O Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body ®Car Dealer Q Collection O Crumb Rubber <br /> O Service Station p Hauler O Agriculture Q Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O 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 /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q 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 /> Q 1 O 1 Other: § / <br /> Comments <br /> Inspection Form Included:O <br /> 6Ph.ne <br /> CommentsBuslnes Rep'sSignature Number In ctor' Ignat e_ Phone Number <br /> INSTRUCTIONS ON BACK IIE15CIAIMIPILIE1 11[21� 62081 <br /> ■ 0716504.0025 White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® . <br />