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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWMB <br /> (Now <br /> Survey Form Page 1 ! 3 0 4 8 2 7 <br /> CIWMB 181(New 04104) ., <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID �� b I Inspection Type (Fill one) <br /> Site Suffix: i - ` (p , ® 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 Inspected By Inspector <br /> yi Cal it d vw ` a++.���-�p►�'j b'v� w Com. - b -�—�� /1 ccs�+. \ <br /> Ph cal Address <br /> i <br /> Ins action Date <br /> Time Out <br /> Business Rep Title Time In O AM O AM <br /> II .� O PM O PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O 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 Q 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 ® Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility `ENFORCEMENT STATUS <br /> ......._ _...........---- --.._ . . ...----- <br /> 14 HAULING:AN MANIFEST REQUIREMENTS Q Notice Of Vlatetlon Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 1@ PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Detadline <br /> Q Q PRC§42956-RegistrationJDecal in Vehicle <br /> e <br /> Q ® 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pM9 <br /> Q I Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB FII / M / M <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requhed forNOVorIXT) <br /> Q Q 14 CCR§18459.3-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 Q 96krrad 1.13MW Enforc*ment <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q t Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Ik <br /> Q Q Q Itx Kl9M.1-l+rna+� No.:Vloiallons <br /> s i Other: <br /> Comments {L %w3i�-C ►�t �` 7 —nrrt,� t t,, a.�: <br /> 1'CO-_ l ir���f S ►�` '� <br /> t <br /> Inspection Form Included: Q <br /> Comments Included: 1 sl s R 's Signa Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK 62081 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br />