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noVest <br />VOL4vVekt v V V.7S <br />;I Waste Tire Survey & Inspection Report Inspection Report Number <br />°11°�. stateor California <br />CIWM8181(N..04104) <br />Management <br />Survey Form <br />— Page 1 <br />1 6- <br />1 0 7 9 3 1 1 <br />Q <br />ealltomla Integrated Weate Board <br />'art A -Survey _ <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Q <br />Inspection Details <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />TIMID -Inspection <br />Site Suffix: <br />` r, <br />y <br />) <br />y n <br />r <br />_ <br />Q <br />/ <br />Q <br />Inspection Type (Fill one) <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />7 <br />010 <br />/ <br />1 Other: § , <br />® Routine Q Re -inspection <br />Q Referral Q Observation. <br />Local <br />�R/Z_ <br />If Referral, choose referral type (Fill one) <br />Identifier: <br />�QA� <br />C�L� <br />Q CHP Q CIWMB p Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />^� Aw� <br />Inspected By <br />Inspectorte <br />Physicaa/al Address <br />I /941. (� <br />Street <br />C j5S`tate <br />Inspection Date <br />f� <br />Business Rep <br />21P Code <br />Title <br />Time In <br />0 AM <br />Time Out <br />0 AM <br />/ V 9PM <br />.087/ Q PM <br />Operational Status Tire <br />Type <br />• Business Role <br />Storage Type - <br />i <br />Tire Count (WholelPTE) <br />0 <br />I ;A10 <br />` i <br />(Fill one only) (Fill <br />all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />SActive ® <br />Passenger <br />® Generator <br />® Outdoor <br />GPS Latitude <br />� <br />. I <br />- <br />II <br />r <br />UTI <br />IO <br />' <br />Q Closed Q <br />Altered <br />Q Hauler <br />Q Indoor ' <br />Longitude — <br />_L <br />T <br />I� <br />__-------����--�--J�� <br />I <br />I <br />I <br />IO <br />Q Inactive Q <br />Q Planned Q <br />Truck <br />OTR <br />- Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />* Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />010 <br />1 Other: § , <br />Comments '�2 %�•wS�c �..� � LL>G/GlQ y"(-�C Gy�ra�l,�Ltc./%�,/ !�/12f L[,9y�C�� <br />le <br />I <br />Inspection Form Included: Q <br />Comments Included:Q <br />B ess Rep's ignature Phone Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorect: rE X .R M P 1 L E I! 2 3 62061 <br />White Copy: CIWMB- Yellow Copy: Operator - — Pink Copy: LEA ® 0 <br />