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■ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rr= <br /> Slat.of1alllernia Survey Form - Page 1 13 - 1 01 3 9 9 2 <br /> CIWMB 181(Naw 04104) <br /> California Integrated Wavle Management Board <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details — <br /> TPID• - / Inspection Type (Fill one) <br /> Site Suffix: �7 y Q Routine 40 Re-inspection Q Referral Q Observation <br /> Local l If Referral,choose referral type(Fill one) <br /> Identifier: �jQ CHP Q CIWMB QComplaint QEducational Visit <br /> Q Other <br /> Business or Facility Name 2, ` Inspected By Inspector <br /> Physical Address 3 - / Q6.0" <br /> Inspection Date C) <br /> Time In Time Out <br /> Business Rep Title Q AM O AM <br /> jPZ1 L � /� 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 /> r *Active Q Passenger i Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR O 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q O •PRC§42951-Waste Tire Hauler Registration and Transport of Tires r, <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. ' <br /> O 0. PRC§42956-Registration/Decal in Vehicle �' `.• �- - <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements a <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days s <br /> Y. .: ., <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> tea M, <br /> , <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers i.Y r rag y <br /> O O 14 CCR§,18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: , <br /> O O § a : ���; :���°.' Ste• �,: <br /> Comments - <br /> /ak 7 <br /> Inspection Form Included:Q <br /> Comments Included:Q ��'' <br /> Busutess Reps ignature Phone umber Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK �` 'r IdIXIAIMIPME1 111213 <br /> 62081 <br /> 0716504.0027 White Copy:CIWMB Yellow Copy:Operator Pink Copy-.LEA <br />