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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of WMB1ali(New Survey Form - Page 1 1 6 - 1 4 2 5 7 4 4 <br /> CIWMB 181(New 04!04) <br /> California Integrated Waste Management Board <br /> Part A- Survey .- BLUE OR BLACK INK-PEN <br /> Business Profile J Inspection Details <br /> TPID- _ i Inspection Type (Fill one) <br /> Site Suffix: I® 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 Address - ` / --' ?// " <br /> Inspection Date D I I Q fr <br /> Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> 0 P 0 P <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)I (FIII all that apply) <br /> t/ 0 Active Q Passenger Q Generator Q Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS Q Hauler O Indoor <br /> 0 ! 0 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 O 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 ENF}RCEMENT 9TAfU$ i <br /> V A i HAULING AND MANIFEST REQUIREMENTS. <br /> O O I PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q ka YIQiBtlott R°xtiftj�lft>I(s <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. ; Cc1�lpltattCe pel�tl)Ins ' <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O .14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB y <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days �� ts?tIVQ1 !"rt,���� <br /> fH -7Fi �s <br /> rO O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years (_7 7 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End Use Facilities } <br /> O O !14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> �f <br /> O O Other: § <br /> Comments <br /> W` �'- 5 A� 5 i - 1�tss�rt l <br /> Inspection Form Included. Q <br /> Comments Included: �15IT - <br /> O;BusiYless&' Se Phone Number ns a Phone Number <br /> - _ - - <br /> INSTRUCTIONS ON BACK j Corledt-07-Incorrect (� � E RMP 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />