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i� Waste Tire SuAy & Inspection Report Inspection Report Number <br /> State afCali(Now Survey Form - Page 1 1 $ 1 0 2 5 7 4 6 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-_Survey _ BLUE_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 2 Q Inspection Type (Fill one) <br /> Site Suffix: 7 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP 0 CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility NameInspected By Inspector <br /> t <br /> Physical Address <br /> 0500 t+ar�uP, <br /> �f_ Inspection Date <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> QPM QPM <br /> 'rte flv�r��« 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 /> ®Active is Passenger ID Generator 4&Outdoor <br /> 0 0Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> O O inactive ®Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet Q Government 0 Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility FC1JJ�[ NJTATU$ <br /> { All <br /> .,. 11 <br /> O 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0:0. <br /> 4tlel�:Ctf VloFatlan Q Extttnslon. <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. ampillln i dlfle <br /> O O PRC§42956-Registration/Decal in Vehicle j <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements j� tp m m <br /> •14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from C1W M8 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 daysM*0V QrEKn; <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years "``"" <br /> e)'CRtQ 14 CCR 18460.2-Manifest System Requirements for Registered Waste Tire Haulers n Wo <br /> _ <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities F yam' T l r f <br /> Q Q 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> , Z <br /> 0 0 Other: § <br /> CommentsFlte,j&�l 4MC7 kut'vire-1 l\eZ.,0 r'4. /-,t PVW.-t"�.V/�e , <br /> .inspection Form lncluded: 0 <br /> Comments Included: Q . - ��� -� I 761 <br /> Business up s 3 gnat Phone Number nspe Ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKME- +0.''.i P L �• 12 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />