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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CIIM f 81jNew Survey Form - Page 1 1 - 1 0 1 4 8 6 6 <br /> CIWMB 181(New 04!04) <br /> Callfornla 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: 17 © l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �' If Referral,choose referral type(Fill one) <br /> Identifier: 1 Q CNP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business o Facility Name <br /> Inspected By Inspector <br /> Physical Address / 3 <br /> Inspection Date v / / / <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> ���� Operational Status Tire Type Business RoleStorage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) t [� O <br /> i 1 0 Active Q Passenger O Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude — Q Planned O OTR O End-Use Container <br /> I - <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 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 <br /> .. .. _ _.,_.. - - ,�[ '.J► �{ x %f ��i�� y,.�i. i/may i i" t '. , <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires a 4 r <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> s��OO14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWM6 Ta . <br /> , +,F:.• sr - . �.•_ <br /> O O 4 <br /> 14 CCR 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days i.✓ �: <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers I _ <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities = <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O 1 Other: § L <br /> Comments Vv61�GG/ 64,-- 1 l�e�- In�civ�ITGJ� -f�4 O>`51 7 . M i� I LI�� <br /> n 2-&2-&(- a (� !L�412- L.f • if � ll�y 7C2rl? .�c�T's t . l S <br /> ©<..�}- W,6-fes l'R-5_ `f\jo v c'a ION 4-(L>, <br /> Inspection Form Included: Q / <br /> Comments Included: Q . 3" <br /> B R p's I ure Pho a Number Ins ctor's Signature Phone Number <br /> y <br /> INSTRUCTIONS ON BACK 101 A p L f 62081 <br /> _ %1/vi✓J <br /> While Copy,CIWMB Yellow Copy:Operator Pink Copy:LEA <br />