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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 3tatated aBteM Survey Form - Page 1 1 1 - 1 0 0 6 5 1 7 <br /> CIWM8 181(New 04104) `r a <br /> Calllomla Integrated Waste Management Board J <br /> Part A-Survey _ _ _ _ _ _ BLUE OR BLACK INK PEN <br /> Business Profile — i Inspecgon Details ---- <br /> TPID- q c� Inspection Type (Fill one) <br /> Site Suffix: 3 ( ` - _ 0.Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP <br /> Q CIWMB Q Complaint . Q Educational Visit Q Other <br /> Business or Facility Name - - <br /> Inspected BY Inspector <br /> `I� 6—k <br /> T�1 <br /> Physical Address 3 t p l <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> S� (9 3 PM Q PM <br /> � 1 Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f (Fill one only) (Fill all that apply) (M 1 all that apply) (Fill all that apply)' <br /> ®Active Q Passenger •Generator Q Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS 0 Hauler Q 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) <br /> QNew T <br /> ire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Disrnander Q Tire Derived Fuel <br /> Q used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber C <br /> Q Service Station Q Hauler Q Agriculture Q Shredder I*Other ` c1 �g <br /> Part B-Inspection of Waste-Tire Dealer,Generator,Hauler and End-Use Facility. <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers, <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14.CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CGR§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 /> 0 O 14 CCR§18459.3-Retention of Manifest Fortes and Tire Trip Logs for 3 years <br /> O O 14r.COR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0, 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 01 O Other. § <br /> Comments 41 %6=0, <br /> 1 o,r- -CncE/✓L (/ Entered <br /> Inspection Form Included:Q <br /> Comments Included: --- -- `l 53 76248 <br /> - Bu—sinesRep's Signature <br /> Phone Numbs - <br /> Phone Number. <br /> INSTRUCTIONS ON BACK` ® 03 <br /> ? AIMIPILIE ; 62081 <br /> ■ Whits Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA © ■ <br /> 0529204.1180 <br />