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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State C1WM 181(NowCaliforniSurvey Form Page 1 1 4 10 2 5 6 2 7 <br /> CIWMg tg1(New 04lOb) � + <br /> Ca IIforn la Integrated Waste Man agernent Board <br /> Part A- Survey BLUE OR BLACK INK-PEN <br /> Business <br /> Business Profile Inspection Details <br /> TPID- _ Q Inspection Type (Fill one) <br /> Site Suffix; Q Routine Q Re-inspection Q Referral ® Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: /GIS if� x � j f� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r / f l Inspected By Inspector <br /> r",Gy E3, <br /> / ' <br /> Phy-ssical Address r C" <br /> Inspection Date [l I 'Z ' 7 I <br /> !� <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <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 /> ' J ® Active 0 Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility !ENFORCEMENT STATUS - <br /> .. ... .l <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires NotiC6 Of Violation Q fwJiterl )Art <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Cornpllarice Deadline F �fY <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 0 O ! 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 74 CCR§ 18459.7(a)(b)(c)- Trre Program ID Number from CIWA48 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requffed l'orNOVtSCQf�} ? <br /> _ U <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.7 Manifest System Requirements for Registered Waste Tire Haulers RemoQSI f q <br /> Q Q 1 14 CCR§ 18481 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> t <br /> G <br /> l <br /> D <br /> Tire R <br /> ® <br /> 14 CCR§ 18462-Manifest System Requirements for Tre eaers or Waste Tire Generators <br /> Q O Q itt �ithFlrtt4ta�k �s�'� •' Y,�f <br /> Other: § <br /> Carrrrrtents 4 ��-1� �'�i �" !0 d V_ fn f <br /> Inspection Form Included: Q <br /> Comments Included: Q - Wr <br /> Business ep's Si re Phone Number fns ctor's S gshone Number <br /> INSTRUCTIONS ON BACK rrelctc� Incorrect_ cl 1Jl J E X A NI P EI t�1J 62081 <br /> ■ Enterea Wnite Copy:(;IWMB Yellow Copy:Operator Pink Copy:LEA <br /> :FI cop <br />