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Waste Tire Survey & Inspection Report Inspection Report Nurrlber <br /> State as <br /> CffM of California -Survey-Form - Page 1 I 4 - i .0 0. 6 4 4. _ <br /> CM/MB 181(Naw nage - <br /> CallfomlalntegratetlWasteManagemerdBoard BLUE OR BLACK INK PEN <br /> PartA-Survey _ __ - <br /> { Ins ectiomDetafls - <br /> TPID Inspection Type (Fill one) <br /> Site Suffix 7 �� 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date I Q 7 I I {6 l <br /> f�3ZO ` 1 - <br /> 5 ._.- .1... Time In Time Out. -- <br /> Business Rep Tide /� (� l AM O AM <br /> PM PM <br /> Operational Status Tire Type' Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that.apply) <br /> Tire Count(Whole/PTE) 7 49 t <br /> Active Q Passenger Q Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler. 0 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 Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismander Q Tire Derived Fuel <br /> Q Used nre Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder •Other <br /> Part.B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> lfi `�� <br /> Q Q PRC§42951-Waste Tire Hauler Registration anc Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste The Haulers. I ' < <br /> Q Q PRC§42956-Reglstration/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 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 /> Q Qo.. $ . <br /> 14 CCR§18462--Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 010 Other. <br /> Comments — <br /> Inspection Form.Included:Q <br /> Comments Included:0,Bu ness Rep's Signature Phone Number In ure __Phone Number_ <br /> i 62081 <br /> INSTRUCTIONS ON BACK p L l ■ <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy.LFA <br /> 0525804.0171 <br />