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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stateof rnia Survey Form - Page 1 ( 7 - 0 <br /> CIWMBBl81 181(N{New 04/84) <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: 3 ? 4 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Ac"e`sss <br /> Inspection Date <br /> � <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> QPM C) PM <br /> Operational Status Tire 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 /> Active Q Passenger 1 ® Generator • Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauter Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <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 [ T.` Yu8 <br /> Q Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires '' d O Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. b5- 'fi�Idli.b <br /> Q Q PRC§42956-Registration/Decal in Vehicle r j <br /> Q Or> <br /> i 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements � I <br /> Q O 114 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMBjLL1 <br /> V . <br /> Q Q i 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tiro Trip Logs within 90 days <br /> Q O 1 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> u y � <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire HaulersiRt <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators s <br /> Other: § <br /> Comments <br /> 9't )Ceaf!� r-e�1, 41 5 <br /> U l �f!'-t�5 . � � G— w c� �'1�V`e-s CL✓`G �"I hrl/e� c>r� el�L-� <br /> Inspection Form Included: Q <br /> 5 3!--7 4466-219s16 <br /> Comments Included: Q - -- <br /> Business Rep's Signature Phone Number Ins tar's Sig aT�TPhone Number <br /> i.< , ,r� �" -T - 62081 <br /> INSTRUCTIONS ON BACK <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />