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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate of California <br /> C1WMB181(Now 04104) Survey Form - Page 1 1 3 10 2 5 7 41 <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: 0 670 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMI3 Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � T��� t1` Inspected By Inspector <br /> Physical Address <br /> Inspection Date O �� � � / 0-5 <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 Storage Type <br /> Tire Count(Whale/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �j <br /> 0 Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <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 /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 10 Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility : ENIORCMENT.,STAY` . <br /> V. A HAULING AND MANIFEST'REQUIREMENTS n Fid <br /> O Notkpi%Of Violation ` r <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires (` <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. j bon liance DGiKdtine <br /> 1 �' <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements i Data <br /> 14 CCR§ 18459.1 (a)(b) (c)-Tire Program ID Number from CIW MB <br /> OjO -� <br /> O ! O (Rsqulredf Ira . <br /> 114 CCR§ 18459.21 -Submittal of Manifest Forms and Tire Trip Logs within 90 days % ✓�s t x <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> b.,:>i,f„ '13f <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities s.r <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire GeneratorsI A" r'y �� �'% ��y <br /> O O 'Other: § <br /> Comments / j1.4���jZG �j�l�y - �C �OY✓/s�t..Qs-j �C�. <br /> +Inspection Form Included: Q. <br /> - <br /> Comments Included: <br /> s Rep's Sign r Phone Number ec ignat— <br /> Phone Number <br /> INSTRUCTIONS ON BACK Cprr incorrect: X�% q A M P L E 1T2 3 62081 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />