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. Inspection Report NumberWaste Tire Survey& Inspection Re ort <br /> State of California <br /> ■ � <br /> CIWMB 181(New 04104 <br /> Integrated Waste Manageage)rnent Board Survey Form -i Page 1-- - 1 9 - 1 .0 0 6 6 2 3 <br /> C�IUam <br /> Part_A-Survey BLUE OR BLACK INK PEN <br /> Buffrl t Profliti - f pectior!-Detalis <br /> 9 - <br /> I TPID 1 � Inspection Type(Fill one) <br /> Site 8uffbc v t ®Routine Q Re-inspection Q Referrer Q Observation <br /> Local r ( If Referral,choose referral type(Fill one) <br /> _pA <br /> Q CHQ CIWMB Q ComplaintIdentifier: S .Q Eduratlon8l Visit 0 Other. <br /> Business or Facility Name v -. <br /> Iri""Wd By Inspector <br /> Physical Address _.- _ _-_._ ____. 3� ! 6)j 6) i <br /> strew I <br /> Inspection Date <br /> ^,•,re Time In Time Out <br /> �. <br /> Business RepTitle ` 't O AM i ., O AM <br /> IPM V ` 1 5 ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPTE) , D (Fill one only) (Fill all that apply). (Fill all that apply) (Fill all that apply), <br /> . ' #Active 0 Passenger ®Generator Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS <br /> Q Hauler Q Indoor <br /> Q Inactive QTruck <br /> O <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fillallthatapply) <br /> ®New Tire Dealer QAuto Repair Q Trucking Fleet QGovernment QRetreader QDismantler <br /> Q Tire Derived Fuel <br /> ®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 /> Q Q. PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42153-Contracts with Registered Waste Tire Haulers. <br /> Q. 0 PRC§42956-Registration/Decal in Vehicle <br /> Q Q +14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§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 /> Q ® 14 CCR§18469.3-Retention of Manifest Forms and Tire Trip.Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q I Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q; 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other; <br /> CommentsttisU� �._ def _ � �L_.�i �.C>O <br /> Inspection Form Included 1 // <br /> Comments Included Q �t0 Aln <br /> i?Bust s n ure• Phone Number °° ector's Signature Phone Nlanber <br /> INSTRUCTIONS ON BACK AXIAIMI P 1L p Z I I 62081 <br /> ■ White CIWMB VelWo6w- per�or Pink Copy LEA © ■ <br /> 0525804.0150 <br />