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u Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateof181(New Survey Form - Page 1 1 1 - 1 0 1 3 4 9 6 <br /> CIWMB 181(New nage Y <br /> California Inlegrotad Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- inspection Inspection Type (Fill one) <br /> Site Suffix: r 0 Routine Q Re-inspection Q Referral Q Observation <br /> I'I Local / If Referral,choose referral type(Fill one) <br /> Identifier: ��d1 �/p��� <br /> h Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - -- _ <br /> Business or-Facility Nme Inspected By Inspector <br /> 103 <br /> Physical Address lJ .7 <br /> Inspection Date U( / 07 <br /> (�f 7 Time Out /O <br /> BusinessTime In/ Rep Title AM AM <br /> /I <br /> O : ..2- 7/ Q PM I D / O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply)I (Fill all that apply) <br /> 0 Active 0 Passenger •Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) L <br /> Q New Tire Dealer Q Auto Repair 0 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. <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 /> Q Q Other:-§ <br /> Comments )t Q2° &V � _ Ko a9� <br /> W�'s'ft �ti a*t S,7e a14;4 7.^t aft �%z P n n- %irC �-o %��►i <br /> alttw <br /> :Inspection Form Included:Q <br /> Comments Included: IUa.�4¢� � � <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK E X �A P E I111213 62081 <br /> ■ White Copy:CIW MB Yellow Copy:Operator Pink Copy LEA ® ■ <br /> 0618604.0022 <br />