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-set <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of <br /> ClWM Survey Form Page 1 f 2 . 1 fl 2 2 4 <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 /> i TPID- g � Inspection Type (Fill one) <br /> Site Suffix: O O Routine If Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> I <br /> Identifier: <br /> 0 CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business RepTitle O AM Q AM <br /> QPM QPM <br /> Operational Status Tire Type I 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 /> ® Active Q Passenger I*Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive '® Truck <br /> Longitude - I O End-Use Q Container <br /> O Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair 0 Trucking Fleet Q Government O Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility l ENFQRCEMENT STAT.US_.:-...._ <br /> V A HAULING AND MANIFEST REQUIREMENTS NOf Violation <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires OoNce. Q Extenalon <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. I Compliance Deadline <br /> 0 ; O PRC§42956-Registration/Decal in Vehicle <br /> O 1 O ,14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements paw <br /> O O 74 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I m <br /> Re u1md for NOV ar <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days ( 9 om <br /> O O 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 i Q Reerred/MMAnfo 6Rt, <br /> O O :14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ., .y.'1-"'tea.-• V_d��Y <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators f <br /> it► lRoinRltatt��;� N,p-,�Y��+� y ��Ss�� <br /> 0010 1 Other: § 7` t._� q�:i `[ <br /> Comments t� ,� /����W 1A�. ���oL. �D1K�¢.t'� v'1����• l "'��r,�^�-"�Y>,M�.� <br /> �1ar�Gets �t�rQ.s (/ H,sh ( . <br /> ti vim--� 9�•-�,a - � cane�. or- Is .r 'ta 1� <br /> wtLS�r-A tip-wW✓ktj�r_S+,VAk 5 t� 4VP <br /> �T <br /> Inspection Form Included: Q' �,.A - <br /> Comments Included: () � � _" — _ <br /> Business Rep's Signat a Phone Numbera Phone Number <br /> - - - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: C' VJ"JeL ET 112 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />