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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State California Survey Form - Page 1 1 4 - 1 0 2 8 8 0 9 <br /> CIWMS 185(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-_Survey BLUE OR BLACK INK PEN <br /> usiness Profile Inspection Details <br /> TPID- ff Inspection Type (Fill one) <br /> Site Suffix: (� b 8 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physics s l v ii, <br /> Inspection Date 0 <br /> Time In Time Out <br /> Business Rep Title - O AM Q AM <br /> { ' QPM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r !� ®Active ® Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 0 Other <br /> Part B Inspection of Waste Tire Dealer,Generator, Hauler and End Use Facility ( 10"dkM T-8T T119 <br /> 77 <br /> 0 0 <br /> iltpltltJ$tl 0 Eltndori <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> . <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Si f19p #> rItltlttF <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0 m <br /> 0 14 CCR§18459.1(a)(b)(c) Tire Program ID Number from CIWMB ' - ---+ <br /> 0 <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> V- <br /> 0 0 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 /> 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 - ROM <br /> - <br /> Comments ( <br /> toc) wr-S Dkl <br /> i <br /> Inspection Form Included: 0 ^ ..- � S <br /> .w J mop <br /> Comments Included: 0 --- - -- - �" b 1`)3- <br /> j Business Reps Signature Phone Number / __ - I �_ _ - <br /> fnspector's nature a Number <br /> ��,. � � 62081 <br /> INSTRUCTIONS ON BACK L°;!fr <br /> V�s ; f ^_ i <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:t.EA <br />