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i , Waste Tire Sur. y & Inspection Report nspection Report Number <br /> Stat <br /> gratedCalifornia <br /> Survey Form - Page 1 ! 8 - 1 0 1 4 7 4 9 <br /> CIWMB 181(New 04704) <br /> California 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: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> y <br /> Ph ics al Address y ( ( d <br /> y-o <br /> Inspection Date f Z J O 2 I d <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> I O PM O PM <br /> `r Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 0 <br /> (Fill one only) (Fill all that apply)I (Fill all that apply) I (Fill all that apply) <br /> 1 I& Active 0 Passenger Generator Outdoor <br /> Latitude <br /> O 1 O Closed Q Altered <br /> CIPS i Q Hauler Q Indoor <br /> O 1 Q Inactive Q Truck <br /> Longitude O Planned Q QTR O End-Use Q Container <br /> i I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ®Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> ' 0 Service station QHauler <br /> Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility EN .. CSM 4 <br /> V' .} i HAUI NG ANIXUAN(lWOT REQUIREMENTS s S <br /> Q Natian ss � : <br /> Q O 'PRC§42951 Waste Tire Hauler Registration and Transport of Tires �- <br /> gi <br /> O Q PRC 42953-Contracts with Registered Waste Tire <br /> Haulers. <br /> § 9 - >' Q ; <br /> O O - <br /> �PRC§42956 Registration/Decal in Vehicle .,_' •= •;;y,?�mn� �'�%%u=zj�; <br /> 14 CCR§ 18459 Responsible Entities Complying with Manifesting Requirements <br /> l Q h <br /> Q 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 010 <br /> 14 CCR 18459.2.1 -Submittal of Manifest Forms and Tire Tri Logs within 90 days <br /> § P 9 Y !. !.,�.•y!/y./�/✓,; sig:.,.iy�i <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0- fi� /%•: <br /> ! <br /> O O <br /> 114 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O ; O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: /1 <br /> Comments r x fS�l•y/fi/3/�%/ w. %%/ii,;,,��j, <br /> ^ /t/Ij,TCJ�f"� / l'f�i � ! 1 I -�7 <br /> Cz <br /> � w- -LJ U�. Cl (�✓l�`� u57✓n�i <br /> Inspection Form Included: Q � /l ILI <br /> / <br /> Comments Included: Q - fIgnature <br /> 1 Business Rep's Signature hone Number actorPhone Number <br /> .. _: 62081 <br /> INSTRUCTIONS ON BACK X A M rr1 2 <br /> h <br /> White Copy CIWMB Yellow Copy.Operator Pink Copy:LEA <br />