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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Suts of <br /> CIWM Survey Form - Page 1 1 9 - 1 0 1 3 4 6 2 <br /> CIWMB 181(New 04104) <br /> Calllomia Integrated Waste Management Board <br /> Part A SurvM BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Q Inspection Type (Fill one) <br /> Site Suffix: / 1J 1 7 $ d / 0 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier. �aK V�� r h �— Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 �u�gggjyj�0!/.� <br /> y Inspection Date O 4 -2 Q 6 <br /> Time In Time Out <br /> Business Rep Title / O AM O AM <br /> Its PM O 0 PM <br /> — --- – Operational Status Tire Type Business Role Storage Type <br /> / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) I , b <br /> Active 0 Passenger �Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 1 <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Relreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body IS 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 /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O, PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O 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 1 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 1 Other. § <br /> Comments folzA' I �A �tLtA� t � i <br /> 4e.° <br /> 4 e:7 <br /> _40 vo:u l <br /> Inspectlon Form Included:Q <br /> Comments Included:Q Busl Phone Numberpe _ S <br /> Ins ctor s Signature Phone Number <br /> INSTRUCTIONS ON BACK I EXAMPLE 1 3 62081 <br /> ■ White Copy:CNVMB Yellow Copy.Operator Pink Copy LFA ® ■ <br /> 0615104.0435 <br />