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"ie o <br /> Waste Tire Sup 3y & Inspection Report Inspection Report Number <br /> State ClWM f 181(Now <br /> Survey Form - Page 1 {. y �J <br /> CIWMB 161(New 00!04) <br /> California Integrated Waste Management Board <br /> 4 3 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I1.13outine 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 Inspected By Inspector <br /> S <br /> Physical Address <br /> o}C,'7 ( Inspection Date <br /> Time Out <br /> Business Rep `Title Time In O AM O AM <br /> O PM O PM <br /> �.-v cz� U wv� <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 j *assenger 41 Generator ® Outdoor <br /> Latitude Q Closed Q Altered <br /> GFS Q Hauler ® 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 /> fg New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 FacilityENPORGEIV VT< Taf44 <br /> V A I HAULING AND MANIFEST REQUIREMENTS lj Notic4 Qf VlAIatlAn <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers, GS1IYI�L�IfiR <br /> Q Q j PRC§42956-Registration/Decal in Vehicle t r ' <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements O 9 0 <br /> I(P Q 14 CCR§ 1B459.1 (a)(b)(c)-Tire Program ID Number from CIWMB st + <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years i <br /> /i <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Rt�f+�tYi'd llyl� 41i '( �/y. <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q i 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (� rt <br /> Q Q Other. § ! ! S'''�/ <br /> 1VlL• ,.J <br /> 11 { <br /> Comments —VMc�\ <br /> It <br /> Inspection Form Included: Q <br /> Comments Included: Q 0, - . <br /> Business Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK j Cori-40D-__(hdorl�9C�;�� � � � A',M4 p � �i t� 3 6zos1 <br /> WhiteCopy:opy: <br /> CIWMB Yellow Copy: <br /> Operator Pink Copy:LEA <br />