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Waste Tire Su my & Inspection Report Inspection Report Number <br /> State B 181California Survey rve Form - Page 1 3 - 2 <br /> CIWMB 181(New nage y <br /> California Integrated Waste Management Board ,J - <br /> 5834 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> Ins <br /> Business Profile p <br /> TPID- r Inspection Type (Fill one) <br /> Site Suffix: l7 J �- (`� ® Routine Q Re-inspection Q Referral Q 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 /> 'Physical Address <br /> Inspection Date -- <br /> Time In Time out <br /> Business Rep Title O AM O AM <br /> Q PM O PM <br /> �Z\j�Y', � c ,t i,i <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 /> b J# Active ® Passenger ® Generator ® Outdoor <br /> 0 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 /> 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 ® Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Otlter <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I=NFORCEM-INT-STATUS_ <br /> V'j A HAULING."_ ND MANIFEST REOVIREMENTS Q Notice Of I Flolation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires u <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance E eadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements (iota <br /> Q O 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 (Requ d for NOV or EXP <br /> 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 i Q.'.RefOrrt;rd lfwfflfillB Enforcement <br /> i <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> I i . <br /> I � Iq �j5tlnp!{ nae No Vlaiatlans <br /> Q O !Other: § <br /> Comments _yM ,._ ,r -- _ `t `-� 14� ���� — <br /> l� <br /> �A)G v <br /> Inspection Form Included: Q /.in,,, <br /> `.D�� <br /> Comments Included: Q S" <br /> ep' Signature Phone Number 6 <br /> Inspec is g re Phone Number <br /> INSTRUCTIONS ON BACK I COJ I"adrr®at, (� v, ���k��4 �h�P L�� _ �t �I� 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />