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Waste Tire Survey & Inspection Report inspection Report Number <br /> State CVWM 181(Now <br /> Survey Form - Page 1 - 0 0 8 0 3 8 <br /> CYWMt3 181 thew 0410A) <br /> callfomla 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 <br /> Site Suffix: r/ � . 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 /> 4��11*' — j <br /> Physical Address <br /> Inspection Pate Q , L / O q <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> � � O PM O PM <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) Q t Q © Q b O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Passenger ® GeneratorQ Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude i Q Hauler Q Indoor <br /> Q Q Inactive Q Truck <br /> Longitude - i Planned Q OTR Q End-Use Q Container <br /> s <br /> Business Type (Fill all that apply) <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 40 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 ENF4RGCCCCC ANT TOIS °I <br /> y 'q HAULING AND MANIFEST REQUIREMENTS T fry <br /> �Q N9tttIsQFzy ,... <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Colin <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q . Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Q�p <br /> � r �- <br /> Q Q 114 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from C(WMt3F <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days y <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years n. <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements far Registered Waste Tire Haulers it �' 'I's •� �%yr <br /> O i Q 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities s <br /> 2 <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators � /` <br /> Other: :ys f � <br /> Comments A,- - <br /> 1 c�S'�[[G- �T'!reef l�✓t�t r r. <br /> 90 CQG�� «/ /� t,• g '�ii� �- a1 nc"4Y3• <br /> (�✓L'gl `T'� � � o,rS__�i`- G>;�i r� D� TL�r jv�4 �1r.� - - - <br /> 'Inspection Form Included: 0 /� <br /> Comments Included:01 ,�LafC/NS1g'4'L2 <br /> C7 f �.7Q Q��j <br /> B sine s Rep's Phone Number ect is ture �(7 Pho`nneelNu�Jm6er <br /> INSTRUCTIONS ON CK [Corr Irl rrect_ 115XIA,M p. (r �2U 62081 <br /> WI•ite Copy. IWMB Yellow Copy.Operator Pink Copy.LEA <br />