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tr• <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> m <br /> r SUte of California <br /> CIWMB 181(N..04!04) Survey Form - Page 1 1 9 - 1 01 3 6 6 5 <br /> Callfomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection? p / p^ Inspection Type (Fill one) <br /> Sita Suffix: / J o J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / M Referral,choose referral type(Fill one) <br /> Identifier QAc o� v1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Insp <br /> `f-/ ect r <br /> Physical Address 9 - / �Q <br /> i-W <br /> C1 9 s�Y� Inspection Date D 9 / <br /> Time In / Time Out I <br /> Business Rep &// v Title / ('' 0 AM J / J •AM <br /> PI Q� (e -- t / -` J 0 PM ( - O PM- <br /> v 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 /> 0 Active 0 Passenger 0 Generator 0 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 0 Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 Facility <br /> WQ Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. T <br /> QQ PRC 42956 9 <br /> Re istration/Decal in Vehicle <br /> I § - <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 1 <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB 4 h� <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 114 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years xi 7 x a• it < < '~, <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> t <br /> 00 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 -'< <br /> Q Q Other: § _ <br /> Comments d.-,L <br /> Inspection Form Included:Q <br /> Comments Included:Q !(/ 1 <br /> sines Rep's Signature 4 one Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I EIXI AM P IL I EI 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0629804.0350 <br />