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Waste Tire Survey & Inspection Report p p <br /> uiu Inspection Report Number <br /> StWMEat California Survey Form - Page 1 1 2 - 0 1 3 6 2 <br /> CIWMB 181 04104) <br /> CaBromfa Integrated Waste Management Board <br /> Part A.Survey BLUE OR BLACK INK PEN <br /> Business Prottle Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: / 40 3 9 0 °'� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �y 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 Inspecto <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business <br /> �Rep <br /> r Title AM / 0 AM <br /> 2j <br /> QPM ( 0 Q 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 /> Active ®Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive j *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 /> i <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 F!_ FO'RkfiVIitiNf� <br /> . SING AND MANIFEST REQUIfke NTS <br /> -- <br /> 0.Notice Of Violatipn Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and I runsport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle -- <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date - <br /> Q Q 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 /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years �� t <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators '«wti; <br /> Q 10 Other: § . <br /> Comments <br /> �D w4wy ' <br /> Inspection FormIncluded:Q `{ <br /> Comments Included:Q t+ b' f— — r yam& <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �rFM 62081 <br /> INSTRUCTIONS ON BACK �i�l�' 8 _ X A tM P L E1 111213 <br /> ■ White Copy:CIWM6 Yellow Copy Operator Pink Copy..LEA ® ■ <br /> 0627704.6063 <br />