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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> stateed W-eCalifornia Survey Form - Page 1 1 6 - 1 0 0 6 4 9 6 <br /> CIWMB 181(New 04104) <br /> Caliromla 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: V t�Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one). <br /> IdeMtfler. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other. <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> _ Inspection Date <br /> Time In Time Out <br /> Business Rept Title 40 AM 0 AM <br /> 0 PM 0 PM <br /> -- Operational Status .Tire Type Business Role Storage Type. <br /> Tire Count(Whole/PTE) „l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' r 111111,Active 0 Passenger IS Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS latitude 0 Hauler 0 Indoor <br /> O 0 Inactive •Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader Q Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0. 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 . PRC§42953 Contracts with Registered Waste Tire Haulers. <br /> §42956-R Istration/Decal in Vehicle a. ^;• <br /> 0 0 PRC eg. .�M.' ..t•. <br /> 0 0 14 QCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 14 CCR§18459.1 a b c -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O' 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years � <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> a bEi <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § ` $' <br /> Comments L ' 1 - a i Iy eS ii S 1(�C_C_ <br /> ,f`e..n a a' r S r X�.v.tt� �.�' l'ib-C�'�rr` •y� + — 1�1'Cv w�oaJMt�►v.S <br /> tic-a�L9 twvo\4.� st al� va w..r'� <br /> Entered <br /> Inspection Form Included:0 y[(�Q�R <br /> Comments Included: 4/ - `- ` 6 t 5 S 761 _ <br /> using s Signature Phone Number In p Phone Number <br /> d' ne r; <br /> INSTRUCTIONS ON BACK 5 e;' x rye t 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0529204. 1188 <br />