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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWM of California Survey Form - Page 1 11 - 1 0 1 3 1 2 5 <br /> CIWMB 181(New 04l04) <br /> Callfomia Integrated Waste Managamant Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / O ` -3 Q C, - t Inspection Type (Fill one) <br /> Site Suffix: b f� [ Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: v Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical dress 77 <br /> Inspection Date © 1 9 <br /> Time In ! Time Out <br /> Business Rep Title O AM O AM <br /> 0P 0P <br /> der-4v �h-�Gl-�-� ...�,r- <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 /> 0 Active ®Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � Q Hauler Q 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 /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®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-RegistrabonlDecai in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements <br /> 0 Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments <br /> r <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Busirins Rep's Si IaE to umber insp or's Signa Phone Number. <br /> INSTRUCTIONS ON BA K 1EPrAIMIPILIE1 111273 62081 <br /> ■ Wh Co y:CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0705';04.0342 <br />