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FL Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State Of <br /> ClWM Survey Form - Page 1 i 3 - 100659 <br /> CIWMB 181 tew 04184) <br /> California Integrated Waste Management Board <br /> Sart A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / ,I - O Inspection Type (Fill one) <br /> Site Suffix: 3 .9 g <br /> Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: L C/O,t Gj 0� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> t�/' Inspected By Inspector <br /> eo Gv Or"It f4 14V:P)`z,;t <br /> Physical Address 3 9 - S' r y�ir�✓-0y.¢ <br /> Gm,P 9 2 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM *AM <br /> V V J tkt dCfl". RCJI✓! T / 7 CJ O PM D 9 0 PM <br /> 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 /> t ®Active Q Passenger ' Q Generator Q Outdoor <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 j Q Container <br /> Business Type (Fill all that apply) L <br /> Q New Tire Dealer Q Auto Repair Q 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 Facility1 <br /> ,. . -. .w. . -_. • - <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. ° 'K <br /> Q 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 CtWM6 <br /> Q Q _t <br /> 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 ' r <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 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> . .< .. <br /> Q Q (Other: § t✓ `4w« s' <br /> Comments <br /> /" 7-G) /u, <br /> Inspection Form Included:Q <br /> Comments InclQuded: <br /> uslness R s Signat a Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I EIXI AIMI p IL I EI 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA . <br /> 0628404.0067 <br />