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r�rr <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State California Survey Form Page 1 i 7 - 1 4 4 896 <br /> CIWMB 181(Now 04104) <br /> California Integrated Mate Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection O Inspection Type (Fill one) <br /> Site Suffix: `f� Routine <br /> Q Re-inspection p Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cr � gthir~ C[ ��v Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r ( Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> OPM QPM <br /> �►— <br /> I t`" ""'�'� �� r Operational Status! Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 21 S" (Fill one only) (Fill all that apply)+ (Fill a)i that apply) (Fill all that apply) <br /> f 0 Active 0 Passenger ® Generator 40 Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q PlannedQ OTR Q End-Use j Q Container <br /> Business Type (F0 all that appy) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 kNFQRCEMENT STATUS <br /> 1�.. : <br /> 14A4U.[N.Q AINI ;.M. .IPP T ftE Elf f41�MENr4 -I <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires a Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance,.06Adllna <br /> Q 0 PRC§42956-Registration/Decal in Vehicle I I <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pttsM / M / m <br /> Q Q 14 CCR§18459,1 (a)(b)(c)-Tire Program ID Number from CIW MB . <br /> Q 0 114 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Ftogyired forNoV orsm <br /> Q 0 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 Q Rtl4I' t#/CfWM111I :Enforcement <br /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> .fir• -� _ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 Q Olher: § �s�f>E�l"t�q�[ttt�l.`+ NQ ulplt�tlgntl ' - <br /> Comments /I. 1�•�7 'r5" .Kr�-/1 C�-4t fes„ r -- f�� / a Z�/ CCG���'C 3 ✓r FG�S„ <br /> Inspection Form Included: 0 � �/�� <br /> Comments Included: Q Gil --- (XJ <br /> Busi ess ep's S re Phone Number I o Sig re Phone Number <br /> INSTRUCTIONS ON B CK f C>�f7'iE � fj3 L ]R +� �VIFP�� # 3 &2oi31 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />