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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of C rWMB California Survey Form - Page 1 1 9 . 1 01 0 6 7 4 <br /> CIWMB 1111(New nage <br /> Catifomta Integrated Waste Management Board BLUE OR BLACK INK PEN_ <br /> Part_A-SurveY <br /> Business Profile Inspection Details <br /> TPID- I (I -� - ` Inspection Type (Fill one) <br /> Site Suffix: e Routine Q Re-inspection Q Referral Q Observation <br /> Local /n' tt If Referral,choose referral type(Fill one) <br /> ^ <br /> V41 <br /> Identifier: l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> T Th c- 3 6) - / o Frage <br /> Physical Address <br /> Lr�- _ Inspection Date O (f I Or 4 odes C ����� Time In Time Out <br /> Business Rep Title/ O AM O AM <br /> 0 PM 0 PM <br /> (((JJJ erational StatusTire 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 /> 0 Active Q Passenger IID Generator O Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 Q 14 CCR§16459.1(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: § }� G iI (� <br /> 'al <br /> Comments Ro _. I j+- , AJee ll� !Df! y �`��,r_`� Pa kn� <br /> J"lGW e_�Dr_- rtin?A � l,fSPflSCt� -Icei�%T /r�+^+�^tZ�iS VIW i�lQiK <br /> &Sc�L<s MD _V%01w <br /> Inspection Form Included:Q �///yyy/ ^ <br /> Comments Included: - l^1/'f�nl �� q &� <br /> Business Re_s Sig_natur Phone Number <br /> Ictor's-nnilruire <br /> Phone Number <br /> INSTRUCTIONS ON BACK A pLIE13 62081 <br /> ■ 0716504.0017 White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />