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Waste Tire Su :Pky & Inspection Report Inspection Report Number <br /> Z egratedlate of CaliteM Survey Form Page 1 1 1 0 2 6 6 4 6 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: " <br /> '� � � � i A Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� �.►lJh1� y G� I O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name f! Inspected By Inspector <br /> �jj <br /> Physical Adc(�essC-5 <br /> � ! <br /> S <br /> Inspection Date <br /> lrte/ Time <br /> Time In Time Out <br /> Business Rep j Title O AM O AM <br /> 0 PM 0 PM <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 ® Passenger ® Generator ® Outdoor <br /> 0 0 Closed ! Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - <br /> 9• 0 Planned Q OTR 0 End-Use Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer 0 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 �F ENFORCEMIwNT$TATU_$ <br /> V l HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Af latlan (� ii9'lf�tf <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Klo <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Dpalldlins <br /> 0 Q PRC§42956 Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements I Dete m m <br /> Q 114 CCR§18459.1 (a)(b)(c) Tire Program IQ Number from CIWMB <br /> t <br /> Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requm9QrOrNDitip /� <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q ReflRrrttllIW�III$ sem' <br /> Q 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 <br /> 0 0 Other: --R., <br /> Comments �C,.-�l-tG� I �Q,y�� C7•.�it' � /' '�- 1 X97393 <br /> 12zvoe 6la-cl- 1 05;-- 015_69;?. <br /> ;Inspection Form Included: Q <br /> Comments Included: Q - <br /> ne s Rep's Signature Phone Number <br /> Insp or s Ignat Phone Number <br /> INSTRUCT�)rlt611�BACK j Correct:o Inctarrsct: ( _Nl I `X A MIP L E f � 3 62081 <br /> _ i <br /> KB White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />