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�R Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of <br /> C1WM Survey Form - Page 1 ! 4 0 2 5 7 6 7 <br /> CIWMB 181 New 04104) . <br /> California Integrated Waste Manapemenl Board <br /> Part-A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: / 6 O 1* 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 <br /> Inspected By inspector <br /> Physical A � 3 C( 1 0 1 ~— <br /> Strom Inspection Date d I D <br /> J Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM O 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 /> p <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> 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 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 E, NT.�TATUS <br /> 7, <br /> A IIA NEM <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires r t� �I�olelon Q,Extension <br /> t <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. l fal�dllt� <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§16459.1 (a)(b)(c)-Tire Program ID Number from CIWM8 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days ( ' t�jr9d°f nNQVOC <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 IW9 �nfot'c�meAt <br /> O Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> O O <br /> 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 5 � i�41i?�tlQ,fft <br /> Q , Q Other: § z •'.» _ f <br /> Comments <br /> �a V <br /> Inspection Form Included: <br /> Comments include - __ 11 15 3 76� <br /> ness Rep's Signature Phone Number Ins p is ure Phone Number <br /> 62 <br /> // 62081INSTRUCTIONS ON BACK � iY'C`Qltlr� � � ; �E - P L P�2 3J <br /> Entered While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> KB <br />