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�t Waste Tire Survey $ Inspection Report Inspection Report Number ■ <br /> StateB 787(New 06104)California <br /> CIWMB Survey Form - Page 1 1 7 . 1 01 0 81 3 <br /> Callfomla Integreted Waste Men <br /> anagemt Beard <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ,I 1 n - O / Inspection Type (Fill one) <br /> Site Suffix: y > b 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> /n�� If Referral,choose referral type(Fill one) <br /> Identifier: Q 6AQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ;Inspected By Inspector <br /> �n/�,e 21LiYe /se�,�►z <br /> Physical Address 3 9 — / 0 VrA/1 40pp <br /> i 7 -P J7 Lome cCie <br /> �� `�lr � Inspection Date O Y 0 7 <br /> tS <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> Q PM Q PM <br /> - - - <br /> Operational Status Tire Type ype 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> i <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� V <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: § ,l <br /> Comments v <br /> .'�- <br /> �%'� 74Y­f C.— <br /> ,oma-r <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK RENFAW-PILIE1 111213 62081 <br /> ■ 0716504.0050 White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® . <br />