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Waste Tire Survey & Inspection Report <br /> rct, Inspection Report Number <br /> State n <br /> C1WM f 81(Nmla Survey Form - Page 1 1 8 1 0 3 3 4 6 <br /> CIWMB 781(New nage <br /> Callfomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: J 2, 6 Cn) G 7, - 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: fy c14D Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ll��[ / Inspected By Inspector <br /> Phy iCc��ff <br /> Inspection Data <br /> ��`�• Time In Time Out <br /> Business Rep Title 2 O AM O AM <br /> O 0 O PM <br /> PM — � — <br /> Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> -'p fl <br /> i Active ®Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned •OTR Q End-Use Container <br /> Business Type (Fill all that apply) <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 •Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility r <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 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 ��i2��� � .4,..t.,�.� /�^�,r..et. �.-►'u j�?�,^s 1 _ Was�+i-_ <br /> ���'� /ted� o•� �2�._..-�r.-- ,�.� -Vii'.--es o,,.p �.-,-._;��.� <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business p s.Signature Phone Number Ins or',.Signature Phone Number <br /> INSTRUCTIONS ON BACK LIXIAIMPII EJ 111213 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LFA �� ■ <br /> 0605204.0531 <br />