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�t Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State rWNl ofCaliforniaSurvey Form - Page 1 1 8 - 1 0 1 3 1 5 6 <br /> CIWMB 187(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: ` ✓� Y (7 T- S � •Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> / I <br /> Identifier: IOCHP Q CIWMB Q Complaint Q Educational Visit Q Other ! <br /> Business or Facility Name 0 _ Inspected By Inspector - - <br /> Physical CG+Af//vti-K' 7 - 0 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title p O AM O AM <br /> /C - /� 7 _0 PM - O PM <br /> 7 Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)! <br /> 0 Active •Passenger ®Generator ®Outdoor I <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body •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 <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q 1 Q PRC§42956-Registration/Decal in 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 CIW MB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-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 <br /> Q 1 Q 1 Other: § <br /> Comments <br /> Inspection Form Included:Q 07 //� J n'- y S <br /> ZA� 'Zv9�'ISldo 7 Wi9�sc1 Ka+rL �4�- <br /> Comments Included:Q <br /> Business Rep's Signatu a Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK jEjXjAjMjPjJ11213162081 <br /> ■ White Copy:CIW MB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0710204.0207 1 <br />