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Waste Tire Sueay & Inspection Repo ro Inspection Report Number ■ <br /> State <br /> of California <br /> C WMB 181(Now 04104) Survey Form - 4 <br /> 10 14 7 4 5 <br /> Callfornia Integrated Waste Management Board Page 1 1 <br /> 'Part A.- Survey BLUEORBLACK INK PEN <br /> TPID- Inspection Type (Fill one <br /> Business Profile <br /> ir Inspection Details <br /> f <br /> L <br /> Site Suffix: <br /> 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local It Referral,choose referral type(Fill one) <br /> Identifier: <br /> S�V, VA 1' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> i Inspected By Inspector <br /> le i <br /> Physical Address <br /> Inspection Date 0 6f <br /> Time In Time Out <br /> Business Rep <br /> Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> 61+51 <br /> Operational Status! Tire Type Business Role Ste 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 0 Generator 0 Outdoor <br /> 0 0 Closed <br /> GPS Latitude i 0 Altered 0 Hauler 16 Indoor <br /> 0 0 Inactive ill Truck I <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 4& Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 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 ENFORCEMEN <br /> 7TSTAT <br /> V A. HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of linolation " <br /> 0 j 0 PRC§42953-Contracts with Registered Waste Tire Haulers, <br /> COMPINtRo 0 <br /> 0 0 PRC§42956-Registration/Decal in Vehicle rrl <br /> 0 0 14 CCR 18459 Responsible Entities Complying with Manifesting Requirements <br /> 0 0 <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR {Rugal, Tor 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days .06 1, lv <br /> 0 i 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_L0 Other: § <br /> Comments 4 z,-P q'4 +fore, <br /> 4C <br /> 4D <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> 0 <br /> il;s Ws ctor's Sign a <br /> usiness Rep's Signatur Phone Number Phone Number <br /> �JIIL <br /> INSTRUCTIONS ON BACK �CorrW . Incorrect_- A MP62081 <br /> I.E <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA ® ■ <br />