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f <br /> ■ State <br /> Waste Tire Survey & Inspection Report urs Inspection Report Number <br /> of California <br /> Clwm8181(New O4I04) Survey Form - Page 1 1 4 - 1 0 1 3 1 4 4 <br /> CIWM <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- t Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-Inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 140— (� ig „ C�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> /nom—• / d Inspected By Inspector <br /> o 7 Q ��Li.� <br /> Physical Address 3 / /'T <br /> c 4y7-�1/i�vv� <br /> Inspection Date l Z / 2 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 0 PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) ,n( (Fill one only) (Fill all that apply) (Fill all that apply) :(Fill all that apply) <br /> �G •Active Q Passenger Q Generator Q Outdoor <br /> O Q 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 0 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 STTIA ATUS <br /> �� _ <br /> � mss' y = 0 Notice Of Violation 0 Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956•Registration/Decal in Vehicle r 1 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data 1 I/ <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> - w � <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days { <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> ��lh,r�r�...F....�.�".a.,ti'�+'K•tay�x-r,�}s3i Y�'-' <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers t <br /> Q 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 /> Comments ley/ - ttt'r cr <br /> 1 /t y4i'�1 <br /> cfl [ Yed /urv,i��►' w �C d,`i _Ae ct <br /> mCecei'�eyf '7�1.t lix.r�. Cry r3i, /iii /v>^esc�s -�•i�'� '� <br /> Inspection Form Included:Q <br /> Comments Included: <br /> s nos ature Phone Number nspeetoes Signature Phone Number <br /> INSTRUCTIONS ON BACKANNNOMEM <br /> E X AI M P L E 12 g 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy LEA ® ■ <br /> 41 11j 7,-:I_14.114 4 4 <br />