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-100 Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB <br /> grated astleMaage Survey Form - Page 1 13-. 1 01 31 7 6 <br /> Califemie Integrated Waste Management Board <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection/ - Inspection Type (Fill one) <br /> Site Suffix: D I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 'flaot Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name c Inspected B <br /> / P Y Inspector <br /> � <br /> Physical Address J <br /> Inspection Date (J—3 7 D 7 <br /> Gtrj` Time In Time Out <br /> Business Rep Title Q AM O AM <br /> O PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 13 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r � <br /> 0 Active 0 Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler IS Indoor <br /> D Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer f 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 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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 1 Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <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 Q Other: § - <br /> Comments <br /> zr"O /'e�c��3✓e w -7� ?�'�� - - <br /> Inspection Form Included:Q <br /> Comments Included: <br /> Business Rep's Sir gnature Phone Number Inspector's Signature Phone Number � <br /> I �i�� p� pit p;l l Jm' 62081 - <br /> ■ INSTRUCTIONS ON BACK h ��� I�� (Iglpl 1112 131 ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0708104.0046 <br />