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u Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cli 181(New Survey Form - Page 1 I G - 1 0 1 3 0 9 6 <br /> CIWMB 161(New nage <br /> Callfomla Integrated Waste Managoment Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I ^ O - O Inspection Type (Fill one) <br /> Site Suffix: VX 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocaIf 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 Addres <br /> I �` 11�-1�Q CR' ^, �•, `� Inspection Date <br /> ���t Wfliyl{ (�S Time In Time Out <br /> Business Rep <p Title/L O AM 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPTE) /: O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger (9 Generator ®Outdoor <br /> O Q Closed Q Altered <br /> ('Ps L.•tltude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) —— <br /> ®New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government O Retreader p Dismantler O 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 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 Q PRC§42956-Registration/Decal in Vehicle t <br /> Q Q 14 CCR§16459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 O 14 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 /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <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 /> 10 1 Q Other: § <br /> Comments <br /> ,--WN— <br /> n • r IS <br /> ' w rrp-eA 0j duo ( sn <br /> Inspection Form Included:Q <br /> Comments Included:Qt <br /> Bualne_ Rep's nature *.' Phone Number Inspe I'a Sign t re Phone Number. <br /> INSTRUCTIONS ON BACK r l IEIXIAIMIPIL E 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA © ■ <br /> 0700,104.0974 <br />