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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Simla CIWM f 81(Now <br /> Survey Form - Page 'I 7 - 7 3 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey_ __ __ — __. _ __ __ _- _ _ — —BLUE OR BLACK INK K PEN <br /> (Business Profile - _ Inspection.Details <br /> TPID- z - / Inspection Type (Fill one) <br /> Site Suffix: f 0 Routine Q Re4nspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - O CHP O CIWMB Q Complaint Q Educational Visit O Other <br /> Business orFaciiityName �r � Inspected By inspector <br /> t� ~` - 1 a 1 <br /> Physical Address � (aa�,a15�s <br /> y77 <br /> Inspection Date <br /> cs c <br /> A �5� <br /> Time In Time Out <br /> Business Rep 1 Title O AM O AM <br /> AA r4gl O PM O PM <br /> -- - — - Operational Status Tire Type Business Role f Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) ( (Fill all that apply) <br /> fo Active O Passenger * Generator Q Outdoor <br /> O � O Closed O Altered GPS Latitude O Hauler Q Indoor <br /> O f 0 Inactive Q Truck � 1 <br /> Longitude - - O Planned O OTR - O End Use O Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> iQ Service Station O Hauler O Agriculture O Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ` <br /> � a`�/i ..,-i^ :a: - „x%�//. %�'-'i.%✓ /yi irS��'. /•i�i,/.ice-,'i /.� /. ,!`iii/% �>��ygrJ;.' <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ��,�y /,✓,j /r, /,, r / j�f <br /> I O Q PRC§42953-Contracts with Registered Waste The Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB �� %yam <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 010 Other: § <br /> Comments <br /> --Vv- A* ,\,cJ <br /> Inspection Forth included: O <br /> Comments Included:Q� �✓ <br /> Business Rep's Signature # y Phone Number _ t _ Phone Number II <br /> g�'z / �•� 62081 <br /> INSTRUCTIONS ON BACK , 6 �►11 P L� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />