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Waste Tire Survey & Inspection Report inspection Report Number <br /> State CIWMf 181(Now <br /> Survey Form - Page 1 3 - 1 4 7 <br /> CIWMB 161(New OAJQA) <br /> CSlifornia Integrated Waste Management Board <br /> 11 <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Pro_ffle Inspection Details <br /> TPID- Inspection Type (Fill one)L <br /> Site Suffix: I p © ® Routine Q Re-inspection Q Referral Q Observation <br /> Local l 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 /> \((( " tt Inspected By Inspector f <br /> Physical AddresslCA <br /> _ 1 Inspection Date i C I 0 <br /> Time in Time Out <br /> BusinessRepTitle Q AM AM <br /> n �t � --- - — 0 PM - - -- 0 PM--- <br /> Operational Status Tire Type i Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> rr <br /> b 10) Active ® Passenger I& Generator 0 Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ®Car Dealer Q Collection Q Crumb Rubber <br /> ® Service Station 0 Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> If s h �'U� �/ / fir r/// lsi� /y :, ice. /�/,i< /j/% %/ /%✓// <br /> 42951 Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 <br /> 14 CCR§ 18459.1 (a)(b}(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q :Other: § <br /> Comments pkv �4� 2 r �'�'�j '--'V, <br /> � a .',,Q Xw v c•~.� cr+ S k-S e w�o --c�� o� �o ��,1ra-�f_ v��n►Inspection Form Form Included: //�� <br /> Comments Inc ded: Q 'Z'Ip <br /> Business Rep's Signature_ Phone Number In ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK ; ` li �l4 p 62081 <br /> ■ �— <br /> White Copy'CIWMB Yellow Copy:Operator Pink Copy:LEA <br />