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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWM 181iNew Surve Form - Page 1 I - 1 2 5 $ 3 3 <br /> CIWMB 181{New nage y <br /> California Integrated blasts Management Hoard <br /> Part A-Survey BLUQ OR BLACK INK PEN <br /> Business Profile _ Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t t ]„ O S O Routine ® Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 5 — �/ "IL <br /> Inspection Date <br /> 3 U 3 5 <br /> 1 Time In Time Out <br /> Business Rep Title O AM O AM <br /> St�tn¢i�t �.P� O PM QPM <br /> Operational Status The 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 /> t ° Active ® Passenger ® Generator 0 Outdoor <br /> Latitude O Q Closed O Altered t <br /> GPS Q Hauler Q indoor <br /> O O Inactive ®Truck <br /> Longitude — Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) I <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility FNFgRQ M NT STATUS __-_-.-- <br /> :-'.A <br /> .JH*k IN Mi NR ST`.f�� UTAtFM INT fn E n <br /> O O Q;:Ntstlfltt fJf Ialatlo Q xtonalo <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. CgCrlplEengp dllne . <br /> Q O 'PRC§42956-Registration/Decal in Vehicle <br /> I <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CfWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (� 4 lief IIINOV or EXT) <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 ; 1jAllB I�r1i9t�9Rlt <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 %if'%.i��/ /�,.y <br /> -�+A` Qfitlt�C►� L ; <br /> O O Other. § <br /> Comments <br /> �7 <br /> 6 t Vp'�^C'"✓� <br /> N <br /> ev, <br /> lip <br /> Inspection Form Included: Q ` _ f� <br /> Comments Included: Q . <br /> Business R�gnatur Phone Number InspePgnature i Phone Number <br /> INSTRUCTIONS ON BACK *_ _syiL3CLA_i�I�PLL� �� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />