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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State er181,N— Survey Form - Page 1 1 4 1 0 1 3 3 1 8 <br /> CNVMB tat(New gage) <br /> Califomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details I <br /> TPID- - Inspection Type (Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local 1� If Referral,choose referral type(Fill one) <br /> Identifier: l_ S � ./ �L/� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (,r "[r7 rl <br /> AInspected By Inspector <br /> �Physi .l`'dr ss <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> OPM QPM <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 O 0 Active ®Passenger 4V Generator ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> 0 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 Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q DismantlerQ Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber n _ <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other -- �R Kk IC¢/Jgf✓ <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility (111 <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: § 1 p <br /> Comments rJAI'' h {' 1t t 1 1� I� ga 4 aT cHSe.X �25 <br /> oij a .C 7-1- n <br /> _C✓r.*� - _rWiP�- Q a-fL.— Cor 04Tr'c.'e-- <br /> )5U k vie qfr <br /> Inspection Form Included:0, <br /> Comments Included:Q <br /> Bu Rep's Signature Phone Number I e ors i na ur Phone Number__ <br /> INSTRUCTIONS ON BAMjEIXKA1M1PiL1E[ I112131 62081 <br /> ■ White Copy:.CIWMB Yellow Copy:Operator Pink Copy:LEA ■ - <br /> 0611804.0135 <br />