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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> it State of Caltfornla <br /> CIWMB 181 IN—04104) $UrVey Form - Page 1 - 7 - 0 3 3 7 8 <br /> Califomla Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN . <br /> Business Profile Inspection Details <br /> TPID- f Inspection Type (Fill one) <br /> Site Suffix: + - Ej © Q Routine Is Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � `meq f` ^` 6-NI Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date O ? ? Q <br /> Time In .J Time Outt <br /> Business Rep Title _ O AM O AM <br /> O PM O PM <br /> � ~ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ®Passenger ®Generator ®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 Q Container <br /> Business Type (Fill all that apply) <br /> 40 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 /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires a. <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O 0. 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 <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years i <br /> Q Q 14 CCR§184602-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System-Requirements for Waste Tire End-Use Facilities <br /> ® Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 O 1 Other. § I �� �y 6/ Y <br /> Commentsyo ralyrem 141- 1 7SLli � - <br /> �„�.io,.rs CTLs t•,��f- at.l��1a-61e. -� t-eyie,� � ��i�r.(�s <br /> (��C.iW tiC.Q b /�•�fh c.V-'o+-� /`�C 7�' f..�ld.�IC•., <br /> Inspection Form Included:Q q p� <br /> Comments Included:Q � �r�/ o� <br /> _ Business Rel ignature _Phone Number Jnsp or's Signature. Phone Number. <br /> INSTRUCTIONS ON BACKt4 i1 P 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LFA ® . ■ <br /> 0609004.0205 <br /> FIDE <br />