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« , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StateB 61iNew , Survey Form - Page 1 11 - 1 014890 <br /> CIWMB 101 New 04!01 <br /> California Integrated Waste Management Board <br /> Part_A- Survey BLUE O_ R_ BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � - � , Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��,�h 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other j <br /> Business or Facility Name <br /> Inspected By Inspector I <br /> t <br /> �IV�Ar�h.tr Z7C- S' <br /> Physical Address � � — ` t� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM O 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 f 0 Active 0 Passenger 0 Generator Q Outdoor <br /> O S Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> i <br /> Longitude — Q Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill ail that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> () Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection 0 Crumb Rubber <br /> Q Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility � I��T I9TATll9 <br /> PRC§ 9Wast Tire Hauler Registration and Transport of Tires <br /> Q Natts� !` 1llol�tlQn' Q Extension <br /> O' <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. " d <br /> O O +plit il119 <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements AW{q I I m <br /> 0 0 14 CCR§18459.1 {a)(b)(c)-Tire Program ID Number from CIWMB <br /> L I <br /> Ohif�iC)Yar <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years _Z��ii � <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers �iI>ttllb•nt: <br /> iii✓� /i,.�,� y <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use FacilitiesXAIV �5.} <br /> O O <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 O Other: <br /> Comments A�(jl-✓ S! <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - — in, <br /> Business Rep's Signature Phone Number In ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK �s j E Xj A1Mj P l L 1 E1 1112131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA . <br />