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Tire Survey & Inspection Report Inspection ReportNumber ■ <br /> J-,C!9!te <br /> ifornia Survey Form - Page 1 i 4 - 4 8 <br /> CIWMB 181(New 04104} <br /> California Integrated Waste Management Board <br /> 11 <br /> Part A- Survey BLUE OR BLACK INK_PEN <br /> Business Profile Inspection Details <br /> TPID- ;Inspection Type (Fill one) <br /> Site Suffix: l v 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: IO CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nam , Inspected By Inspector <br /> GiPhyhical Address - t% ` l^� V`U1 <br /> I Inspection Date © ti / ` '� I ('j <br /> 1�t�N\�•� Time In Time Out <br /> Business Rep Title O AM O AM <br /> r O PM _ O PM <br /> v <br /> 1 \d. Operational Status,! Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) f f p (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger ® Generator Q Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q CDnta'nl er <br /> Business Type (Fill all that apply) <br /> ® 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 <br /> ENFQRCEMEN7$TATU$ M� <br /> p Y <br /> _VA> HAULING AND MANIFEST REQUIREMENTS <br /> -1 --- ---- Q Nptico of:.Violation <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires i <br /> Q Q PRC 42953-Contracts with Registered Waste Tire Haulers. P "f / <br /> § 9 Cam IlanGe i>s�dllns <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> i <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Dete / I <br /> 14 CCR§18459.1 a b c -Tire Program ID Number from CIWMB .,,,;'• <br /> lie fllyd for`IVE71lAr ` <br /> Q 0 14 CCR§1$459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q } <br /> 14 CCR18459.3-Retention of Manifest Forms and Tire Trip 9 for Logs 3 ears <br /> § Y <br /> 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 ✓'c'� <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § eYr'S•:t^:r <br /> \ — <br /> Comments <br /> Inspection Form Included: Q 4SIgna <br /> Comments Included: 0 - sl s ep's Sig re Phone Number Inspector' ure Phone Number <br /> coJ I 62081 <br /> INSTRUCTIONS ON ACK M <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />