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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CjWM f 81(Now Survey Form - Page 1 1 4 - 1 0 2 5 7 2 0 <br /> CIWMB 181(Now 04104) <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: I Z 7 07 -7 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> _ Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> • C` � ��3 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count (Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> v ® Active Q Passenger ®Generator ® Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> C Q Inactive ® 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 0 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 1G�L1 U <br /> Part B- Inspection of Waste 'fire Dealer, Generator, Hauler and End Use Facility EQ RMONT JSTATUS <br /> / l <br /> ;� '.:.,.. O PIO��QetNMEillliftn 0 enlla)rL <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. +�fill�llllrlRey Itdllt <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 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 71L�L.J <br /> ►d( iV - +k EXE <br /> O O 14 CCR§18459.2.1 -Submiftaf of Manifest Forms and Tire Trip Logs within 90 days <br /> Q O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years 9 F <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q , O 14 CCR§ 48462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O Other: § r�� ,� <br /> O <br /> Comments Cd r SIAU– w.-As — - <br /> /1+'�ty Ltse� � rsee,�. �itr .�?Qi1� l�c�i' CA' <br /> Inspection FormIncluded: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Nu or s c Ignatur Phone Number <br /> NO- <br /> iINSTRUCTIONS ON BACff <br /> Ka#-. � 2 3 62Q81 <br /> White Copy:CIWMB Yellow Copy:Operator rink Copy:LEA <br />