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=r , Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWM 181California Survey Form - Page 1 { 4 - 1025825 <br /> CIWMB 181(New 04!04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR R BLACK!NK PEN <br /> .Business Profile I Inspection Details <br /> TPID- 11 �j, inspection Type (Fill one) <br /> Site Suffix: o 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> L �- <br /> � Ct 5 �� Inspection Date C?Time In Time Out <br /> Business Rep /Title O AM Q AM <br /> t��` aYL► PM O PM <br /> Operational Status I Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' (Fill one only) (Fill all that apply) (Fill all that apply) I (FIII all that apply) <br /> 7C> ® Active I Passenger , ® Generator ® Outdoor <br /> O O Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> o O Inactive ®Truck <br /> Longitude _ O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair ® Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection 0 Crumb Rubber <br /> O Service Station Q Hauler O Agriculture O Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT$TAT S <br /> V j A HAULING AND MANIFEST REQUIREMENTS 0 Noticr0f Violation Exx�ft/lt�lt�, <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PAC§42953-Contracts With Registered Waste Tire Haulers. <br /> O � Comptlali46 pegdllne �.r <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O ® 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements p I <br /> �i <br /> O I tO 14 CCR§18459.1 (a)(b)(c)-Tire Program!D Number from CIWMB <br /> O O 114 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 1 <br /> O OJ <br /> 4 CCR§18460.2-Manifest System Requirements for Registered Waste Tire HaulerR�fa <br /> s ter4+f/ SVM POO <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O I Other: § kw< <br /> Comments <br /> A_ 1 ��, l'A �'c'ti� oma... ►-k-c.. �,�.� ��. <br /> kb <br /> Inspection Form Included: O / <br /> Comments Included: O - — - - 5- - ��� <br /> Busi s Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> INS��IT6caNS ON BACK i Co rootincQri$¢t _ (.7� I xI Ml P I I EI I I ( I 62081 <br /> . KB White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />