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jjWaste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State o/California Survey Form Page 1 10 3 2 Q 3 <br /> CIWMB 181(New <br /> eg <br /> California Intrated Wavle Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection.Details. <br /> TPID- J � � � Inspection Type (Fill one) <br /> Site Suffix: / (P Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �y� ��� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Bus a =Filityme Inspected By Inspector <br /> Physical Address U 3 <br /> Inspection Date b 3 / / O 7 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> / t 0 Z—' Z 7 ®PM V v PM <br /> Operational Status Tire Type Business Role Storage Type <br /> r /, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply): <br /> Tire Count(Whole/P41) f fy <br /> / / ®Active ®Passenger *Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude – Q Planned It OTR Q 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 ®Other 10,A-h-w <br /> iyn <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q I PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q 'PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities 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 Tire Trip Logs 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 <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire.Generators <br /> 0 , 0 Other: § <br /> Comments 1 12 <br /> w• <br /> Inspection Form Included:W1 . <br /> Comments Included: q <br /> ss Rep' gnature Phone Number nspector s Signature Phone Number <br /> INSTRUCTIONS ON BACK EIX A hk P L E a 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0705904.0344 <br />