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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWME('1811(Now <br /> Survey Form -- Page 1 i - Q 4 796 <br /> CIWMB 181(Naw 04104) <br /> Callfornla Integrated Watte Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q Routine i VRe-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: —�'� ^¢ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> ��Cgfill►^ <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physica Address <br /> /6 ! �„s�-��� Gam- �✓�_� �1� <br /> S / Inspection Date © ! ! <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> O PM 0 PM <br /> Operational Status Tire Type Business Role i Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t�Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive I® 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 •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 �� �` 1TUl <br /> I <br /> f <br /> i%1� !��//i ,.%iii -a_- - <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires - - <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle - <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements [� <br /> 0 l <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from GIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Lags within 90 days <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! d ` <br /> O Q '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 /> f � <br /> Q Q Other: <br /> Comments ,/1/J �!� _rS Z'Lt 7 7L, 4) <br /> U t,' 4- (ckc,_I ,'�' O� �✓ 1 Z-3 'f <br /> Inspection Form Included: Q I �TLit/ <br /> Comments Included: Q <br /> 1 B I p, Sig re Phot a Number In .to a Phone Number <br /> INSTRUCTIONS O ACK 'v /r i IFIX ,�4IM 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />