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Waste Tire Su 3y & Inspection Repor'L Inspection Report Number <br /> Stateo181(NewfCallforniSurvey Form - Page 1 3 - 1025857 <br /> CIWMB 181(New nage <br /> Callfornla Integrated Waste Management Board _ BLUE OR BLACK INK PEN <br /> Part A- Survey_ <br /> Business_ Profile Inspection Details <br /> TPID- , Inspection Type (Fill one) <br /> Site Suffix: ' g f ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: y -�- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r Inspected By Inspector <br /> I <br /> 114hysicalddress <br /> Inspection Date <br /> — Time In Time Out <br /> Business <br /> �Rep <br /> ' 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude O ® Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> Q inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> i <br /> Business Type (Fill all that apply) <br /> Q 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 0 Agriculture Q Shredder Q Other <br /> Pall B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility "I� GII� N' STA'fU8 <br /> Ext- nalcrt._ <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> At �ilt )ipp <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QO 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements ! / <br /> Q <br /> O . 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 <br /> O O <br /> Q O 14 CCR§18459,3-Retention of Manifest Forms and Tire Trip Logs for 3 years , <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> (! <br /> j <br /> Y " e14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities O <br /> 14 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § %y L� %-- <br /> Comments �GI(1�'r� �/i�' `'t[,� s+✓l i car ��qc. '�"�v�� �r-��,a"� w i jl <br /> 1 .� ,�-e� 4-1k-a- c A—L <br /> — ©►� --�"iv�2.�}` P v Ovid ci. <br /> 412 —H, �rC'i U �c-,� (S fG-re liiA'n!-O-- "N J aS+— 4r _-0, IL <br /> Inspection Form Included; Q <br /> j Comments Included: Q - — ---���q 4 ^�� <br /> -- T <br /> ess Rep's Signature Phone Number Inspec Signature Phone Number <br /> /� �y011-11", ���� 62081 <br /> INSTRUCTfONSN BACK .,� . ; %y C,9 P L l E l 1 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />