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�L Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br />CIWMf181 (Nmla Survey Form -Page 1 I Z- 1 0 0 6 6 9 9 <br />CIWMB 181 (New 041 4) <br />California Integrated Waste Management Board <br />'art A - Survey BLUE OR BLACK INK PEN <br />Business Profile - Inspection Details — <br />TPIDSiteI Z f <br />Site Suffix <br />Operational Status <br />Local <br />Identifier: 5�� 'p'r�in�•� <br />Business Role <br />Business orFacility Name 1 <br />— <br />Address <br />Physical Address <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active <br />® Passenger <br />Business Rep <br />Title <br />0%H• --r:;- <br />Tire Count (Whole/PTE) <br />r r <br />GPS Latitude <br />Longitude — <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet <br />Q Used Tire Dealer 0 Auto Body 0 Car Dealer <br />Q Service Station 0 Hauler 0 Agriculture <br />0 <br />Inspection Type (Fill one) <br />• Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />S <br />Inspection Date © y -Z Q /_ <br />Time In Time Out �O <br />0 AM O AM <br />• QPM QPM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active <br />® Passenger <br />0 Generator <br />® Outdoor <br />Q Closed <br />0 Altered <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Fors and Tire Trip Logs within 90 days <br />Q <br />Q Hauler <br />0 Indoor <br />Q Inactive <br />0 Truck <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />0 Government 0 Retreader <br />0 Collection 0 Crumb Rubber <br />0 Shredder Cp Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIW MB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Fors and Tire Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />010 <br />1 Other: § <br />Comments --I n r /r 1 A r <br />Dismantler Q Tire Derived Fuel <br />�Ir'�'Z��W�Jt/J�1•�7�=i�i7P_f�GZ���`2+'(' �1f►�iLcf?iic3 <br />f f ►zwa,lu 1 <br />inspection Form Included: (� <br />Comments Included: Q <br />Business Rep's SIgAt <br />INSTRUCTIONS ON BACK <br />■ While Copy: CI W MB <br />0i6N9004. 0220 <br />Yellow Copy: Operator Pink Copy: LEA <br />62081 <br />�■ <br />