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« , Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CIWMf 181(Now <br /> Survey Form - Page 1 i 9 - 0 2 5 $ $ <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- Inspection Type (Fill one) <br /> Site Suffix: a 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 <br /> Inspected By Inspector <br /> Physical Add�i ass <br /> ,Lh (�v�t <br /> Inspection Date l D I <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 15 0 P 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply); <br /> f t ®Active e Passenger ® Generator 4t Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q 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 Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End Use FacilityEh� �QJ,"",NTITATUS <br /> € 1 ► �t } J t 1' . . ,,...'.. : p N401- of Vroilfttan. Q extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers, �fIlplllltllQa.'IJ�ttdlfrti <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> (� Q 14 CCR§ 1 B459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from ClWMB Ell I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days � tgtJltUfQ1<ocEX7). <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 /> 1�Ali <br /> ill fQlttl�Q <br /> Y F - <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r z a <br /> Other: § / r '�x <br /> Comments <br /> P <br /> V <br /> Inspection Form included: Q' <br /> 05 <br /> Comments Included: Q — - - - <br /> siness ep's Signature Phone Number Inspector's Signature Phone Number <br /> n•} ✓ r i y'i, i !/. / T" 62081 <br /> INSTRUCTIONS ON BACK <br /> 0-0, _ L � �L;;ih4 F �t 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />