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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Slate 8181 forma Survey Form - Page 1 1 Q Z n <br /> CIWMB 181(New nage ■ <br /> California Integrated Waste Manag©meal Hoard <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> i <br /> Site Suffix: r A Routine O Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date � � I 0 <br /> G � I v <br /> ry Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> i® Active Q Passenger ® Generator Outdoor <br /> O ' O Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> 0 () inactive 9 Truck <br /> Longitude — O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair ®Trucking Fleet Q Government 0 Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O service Station Q Hauler 0 Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> . - <br /> V A HAULINM*ND MANIFEST REQUIREMENTS Notice Of Wolatlon Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Coadline <br /> O O PRC§42956-Registration/Decal in Vehicle m1 <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Qate I ` III I I I m <br /> O j O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMm B + ! ! 1 L I <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (RBgil d fol'N0V or EXT) <br /> T --- ._._-.........._.......-- —. <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O ! 14 CCR§18460.2 Manifest System Requirements for Registered Waste Tire Haulers 0 Refsrred 1`.IWMS Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O i O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ( 'inompli nae • No Violations j <br /> 'Other: <br /> FOL6 - - I <br /> Comments t <br /> �u4\ <br /> Inspection Form Included: Q /J G <br /> Comments included: Q v '/` /S Wff <br /> Business Rep's Signature Phone Number ec Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK �Cbrrect;10Inca�rract )( �/i � y hdPyl�� � I <br /> While Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />