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i- Waste Tire SL_ ey & Inspection Repor. Inspection Report Number <br /> E, CIWM6181(Now 04/04) Survey Form - Page 1 i 7 - 0 4 7 4 8 <br /> State of California <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details — <br /> TPiA Inspection Type (Fill one) <br /> Site Suffix: ' <br /> ®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 `/j_ Inspected By Inspector <br /> Physical Address <br /> A,y <br /> Inspection Date J � I � © I C> LF <br /> Time In Time Out T <br /> Business Rep Title O AM O AM <br /> • O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> j Q Active Q Passenger Q Generator Q Outdoor <br /> O II 9 Closed Q Altered <br /> GPS Latitude - Q 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 /> 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCLMENT if` T.-1 , <br /> V A_ HAULING AND MANIFEST REQUIREMENTS 01, <br /> Q Nctice bf Vlotattiori <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires - <br /> Q Q <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. CompllastCs 048dllt7g ' <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements I Date <br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> tFra�ftltriztt� Af1 /�i� <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q 1 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 <br /> O Ora S <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> _ - 6n�s . <br /> Q f Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ,y f <br /> Q Q Other: § _ "' � '�• / . <br /> Comments 115 <br /> I <br /> '�'".(la I r�900—333 -- 2,4e03 ��h�.0 VZ�Ilea 4- , L-.,,ri:z <br /> 11p�� . ��I'C'ar�i� (n��11 a^S !� ��, ��KX �' �t^�✓i� _�� _ <br /> Inspection Form Included: Q <br /> Comments included: Q <br /> Business Rep's Signature Phone Number ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK orfs tr -; urrgct X A M F L E 2 3 <br /> �..._ X <br /> Cnf <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />