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V <br /> Waste Tire Survey & Inspection Report Inspection ReportNumber <br /> rU State of Callforn la <br /> CIWMB181(Now 04104) Survey Form - Page 1 1 1 - 1 0 2 5 6 5 7 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> Inspection Type (Fill one) <br /> Site Suffix: 0 cl q 7 �. / O Routine Q Re-inspection Q Referral O Observation <br /> Local .� If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name•/ <br /> Inspected By Inspector <br /> Physical Address <br /> 1 <br /> Inspection Date © S I Q Z I C�> S <br /> Time In Time Out <br /> Business Rep Qp Title O AM O AM <br /> O PM 0 PM <br /> tJ��wrVss� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger ® Generator ® Outdoor <br /> Q Closed 1 Q Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> C) Q Inactive • Truck <br /> Longitude _ Q Planned Q OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair 40 Trucking Fleet Q Government 0 Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service station Q Hauler 0 Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility �..-ENJ%if N STATUS _ <br /> { V"I X HAULING,AcNA.MANIFEST R15QUIREMENTS � - <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Ny�tlge Of Vfoledon Q Extension <br /> O O <br /> PRC§42953 Contracts with Registered Waste Tire Haulers. Corii�t4np0 0eadllne <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Odf .i I I M <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB Ll E] <br /> ' l(1 <br /> O 0 ;14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days qulred for NOV or E)M <br /> �, t i 3 <br /> 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 N r 'd limit B Enforcement <br /> 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities � 1 <br /> 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators - <br /> pJl�tttoe,t- Na,Vlolations <br /> Other: § ' ---- - <br /> Comments J✓��r tl S (�Y►5+'�'�i i L= ' ` �1 <br /> �-7 D"LZg4�vA <br /> eplY41- 111'vt a /all <br /> �� i TT �iC���J � 177�J�/�• <br /> Inspection Form Included: Q <br /> Comments included: 08 e Ig ature ne Number ec or's Slg ure Phone Number <br /> INSTRUCTIONS ON BACK f Correct En orr8 � !1?X t�s 2 31 6zaa1 <br /> White Copy CIWMB Yellow Copy Operator Pink Copy:LEA <br />