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M Waste Tire Survey & Inspection Reportinspection_ - .-Repo_rt <br /> NumberState ■ <br /> CIWMBof California Survey Form•- Page"1 . i 1 - Q 4 6 6. 2 4 <br /> CIWMB 181(New 04104) i ' <br /> Califomis Integrated Waste Management Board <br /> Part A SurveyBLUE OR BLACK INK PEN <br /> Businj Profile -- Inspection Details <br /> - - <br /> TPID- l ` O 1 Inspection Type (Fill one) <br /> Site Suffix: l l ®Routine Q Re-inspection Q Referral Q Observation <br /> Local -_-—� � If Referral,choose referral type(Fill one) <br /> Identifier: { owL J f7^ r CHP Q CIWMB Q Complaint " Q Educational Visit Q Other <br /> Business or Facility Name y <br /> Inspected By_ �� In^or <br /> � <br /> _... i <br /> i ! ��•w �—��f"o4�C" �. <br /> i r I <br /> Inspection Date ! / II i / 4 <br /> Time In -> v inO Out ; f <br /> Business Rep Title i AM O AM <br /> PM PM <br /> Tire <br /> i B <br /> Operational TireT <br /> - P Typo :, Business Role Storade Type: <br /> The Count(Whole/PTE) ' V, (Fill one only) (Fill all that apply). (Fill all that apply) (Fill all that apply) <br /> _ 1 tW Active Q Passenger 4@1 Generator " ®Outdoor <br /> GPS Latitude O" Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use ®Container <br /> Business Type (Fill all that apply) " <br /> Q New Tire Dealer Q Auto Repair ®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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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. s <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q ® 14 CCR§18459 -Responsible Entitles Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459..1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1--Submittal of Manifest forms and Tice Trip Logs within g0 days y <br /> Q. Q 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 <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> . 0 Q 14 CCR§"18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators -1 <br /> :,. <br /> Q Q 1 Other.. <br /> Comments <br /> Insp ectlon Form Included: 7 }� <br /> Comments Included:Q <br /> Business Rep's Sigu e na Phone Number insp Ctor's Signature Phone Numb®r. <br /> INSTRUCTIONS ON BACK J4 �, <br /> �` 62081 <br /> '■ ' - White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA .. ® ■ <br />