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idiffi Waste Tire Survey & Inspection Report Inspection Report Number <br />State CIWMlcallfo81(Nmle Survey Form -Page 1 I - 1 0 <br />CIWMB 181 (New OM04) 13 616 <br />califomia Integrated Waste Management Board <br />Part A - Surve BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -Inspection ( Inspection Type (Fill one) <br />Site Suffix: 6 05- <br />0 Routine 0 Re-inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: <br />(:) CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Address - O <br />3.2 3 <br />Inspection Date <br />Time In Time Out <br />I Business Rep Title C� AM / AM <br />� Z 0 PM D O 0 PM <br />�/ <br />��� ll.� � o - - <br />P / / �" Ote) �t-e.F <br />Operational Status; Tire Type Business Role Storage Type <br />Tire Count (Whole/PTE)n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />' V <br />0 Active 0 Passenger • Generator 0 Outdoor <br />O 0 Closed 0 Altered <br />GPS Latitude 0 Hauler 0 Indoor <br />O 0 Inactive 0 Truck <br />Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader ® Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br />ONA. YQa <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 0 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMBl <br />0 0 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 0 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br />0 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 1 0 1 Other: § <br />Comments <br />Inspection Form Included: 0 tom'"( �Q e /� / <br />Comments Included: - ---- <br />Business Re s Signature Phone Number Inspector Signature Phone Number <br />INSTRUCTIONS ON BACK (E 9C A, P a. E I 1 12 13 I 62081 <br />Yellow Copy. Operator Pink Copy: LEA ® • <br />White Copy. CIWMB <br />4_i r, 1 4_i 4 . 1714 L-1:1: <br />