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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> .r. <br /> CIWM tCallfomla Survey Form - Page 1 1 9 - 1 0 1 0 7 1 6 <br /> CIWMB 181(New 04104) <br /> Callfomla Integratetl Waste Management Board <br /> Part A-I; BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1O Inspection Type (Fill one) <br /> Site Suffbt: 0 3 3 0 `fig' 0 Routine <br /> Q Re-inspection p 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 <br /> Facility Name inspedeed By Inspector <br /> Physical <br /> MA_ t� ( l0 J441-,� FrO / <br /> Igo - <br /> jVtpW� cA cI 5336 Inspection Date D ,J O O <br /> Time In Time Out <br /> Business Rep t� Title O AM O AM <br /> VIN ES p�►�J� O PM O PM <br /> CW <br /> Operational Status Tire Type Business Role Storage TYPe <br /> Tire Dunt(Whole/PTE) fj( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' wQ Passenger Q Generator Q Outdoor <br /> O ®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 ®Other TOW <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 w a ' <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. T ` <br /> Q Q 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 •,v r <br /> Q Q 14 CCR§18459.3-Retention of Manifest FormsandTire Trip Logs for 3 years `'`' . ;-.'•:Y-;; <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Y <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators :.- <br /> Q Q Other: § <br /> Comments ` I r <br /> JU5 �a a[ViA dogs Kot wwAAi wastC iiY&. No i o <br /> Inspection Form Included:Q <br /> Comments Included:Q J ` <br /> Business Rep's Signature Phone Number Ins or's Sig rre Phone Number <br /> I M562081 <br /> INSTRUCTIONS ON BACK EXAM L I;2 3 ® ■ <br /> White Copy CIWMB Yello Copy Operator Pink Copy:LEA <br />