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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> ■ CIWM 181(NCalifomla Survey Form - Page 1 14 . 1 01 3 2 3 5 <br /> CIWMB 181(New nage) Y <br /> Calnomle 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: 1 (j © •Routine Q Re-inspection Q Referral Q Observation <br /> Localit Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other nw9 t - — -- <br /> Business or Facility Name fi Inspected By Inspector <br /> Physical Address <br /> Inspection Date n / ©� / —7 <br /> Time In f' Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> �W�'� - Operational Status Tire Type Business Role Storage Type <br /> 3 r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Active ®Passenger ®Generator 0 Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler O 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 t®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 <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments \ 10 f4,�- Rill <br /> - Tl-_ <br /> Inspection Form Included:Q 29 <br /> Comments Included:Q Busines ep's Signature Phone Number In ctor's Sign-IFIT07 Phone Number <br /> INSTRUCTIONS ON BACK E X P L 12jjj <br /> 62081 <br /> l0. <br /> ■ White Copy:CIWMB a, Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0705904.0349 <br />