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;, Waste Tire Survey & Inspection Report Inspection Report Number <br /> State BCalifornia Surve Form - Pa e 1 I $ - 0 Z $ 3 <br /> CIWMB 181(New 64!84) Y <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- \ r Inspection Type (Fill one) <br /> Site Suffix: ]� L �} J�Routine Q Re-inspection 0 Referral O 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 Inspected By Inspector <br /> Phys, al Add ss <br /> 00 <br /> Q ` � Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> L Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ` V C> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active (k Passenger Generator Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilitySTATUS <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires - o YIQfOtian Q Extension <br /> § -Contracts with re Haulers. <br /> � � PRC 42953 Cttith Registered WtTi <br /> CamRII#ItWptndllRe. _ <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> 0 i O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (R0 t1lrl forNpVor&T) <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers lint <br /> O O 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities - <br /> ,l! 5✓p , <br /> 0 O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators y <br /> 0 O Other: § �- <br /> _ <br /> Comments pyv­UAc� P1 u4_ U <br /> 1 AbUl �. <br /> VQV <br /> Inspection Form Included: 0 -4. <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Ins ctor's Signature Phone Number <br /> `� '� }/ ,ll` IP4 , <br /> 1T 62081 <br /> INSTRUCTIONS ON BACKr1' 4 �.�_L <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />