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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> SCalifornia Survey Form - Page 1 1 9 - 1 0 1 3 5 1 2 <br /> CIWMB 181(New 04104) <br /> Callfomia Integratedgrated Waste Management Board <br /> Part A.Survey _BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- y f Inspection Type (Fill one) <br /> Site Suffix: d I I ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _ 7 Q CHP Q CIWMB Q Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical Address � <br /> 03-7 - <br /> Inspection Date 2 / 1 <br /> Time In Time Out V <br /> Business Rep Title QAM Q AM <br /> QPM QPMJ <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 Q Passenger ®Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q inactive ®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 ®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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Numberfrom CIWMB . <br /> Q Q 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 <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 <br /> Q Q Other: § <br /> Comments �]�C /' yD+�� �,•cam f <br /> _1Q <br /> _ <br /> Inspection Fonn Included:Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number In or s Sig ture Phone Number <br /> INSTRUCTIONS ON BACK x A M P I lalP 2 62081 <br /> ■ While Copy:CIWMB Yellow Copy:operator Pink Copy:LFA ® ■ <br /> A6.1`_i 104.0566 <br />