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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of CIWM <br /> 181( rola Survey Form - Page 1 19 1 fl 1 4 8 0 8 <br /> CIWMB 1B1 Now 04104 r <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> - / A spection Type (Fill one) <br /> Site In <br /> Site Suffix: fj l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sa,,\) � —� SD Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> ast�ow <br /> Inspection Date <br /> s Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM Q PM <br /> Operational Status' Tire TypeBusiness Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � t (7 ' I <br /> 0 Active ! Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> o Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 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 /> 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 1 e-NFQ MMENTSTATUS„ <br /> V ,Ai HAULINE3 A►NO M.AiNIFISBT:REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires i D NIDt1R9'(7f;Vlplatlpn Q Eens{On <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. prtt)ili>llltt~,e Deadline <br /> Q Q 1 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements P��[J] I L� I m <br /> O i O 114 CCR§18459.1 (a)(b)(c)-Tire Program iD Number from CIWMB <br /> Q Q (Rgqulred for NOV or F.k) <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q O - - ---- <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers }14ttxtC�NM !«(l[QrCyhYttt <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators s 5 <br /> a �Iff 1�tai hs <br /> O O Other: § <br /> _ s <br /> Comments <br /> /T 1 475 .1,4k � <br /> TTi�P�.�; l�llS �7'ivit✓ <br /> IylM57 v�iy✓ <br /> Inspection Form Included: Q CZOJ <br /> Comments Included: 0y53 700 <br /> Business Rep's Signature Phone Number ure Phone Number <br /> i,a <br /> INSTRUCTIONS ON BACK rEA; pT� � �T s2oa1 <br /> `._.I�. Z..t_l <br /> ■ While Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />