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Waste Tire Survey & Inspection Report Inspection Report NumberState . <br /> CIWM ' 81(New <br /> survey Form - Page 1 f 4 - 0 0 809 4 <br /> CIWMa 181(New 04104) <br /> California Integrated Waste 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: - 0 Routine ® Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> _ ' Inspected By Inspector <br /> Physical Address - Q <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title Q AM O AM <br /> ' QPM QPM <br /> Operational Status Tire Type j Business Role Storage Type <br /> Tire Count{Whole/PTE) (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> f t 0 ® Active Passenger 0 Generator ® Outdoor <br /> 0 0 Closed 0 Altered <br /> j GPS Latitude ®Hauler ® Indoor <br /> O 0 Inactive 0Truck <br /> Longitude - 0 Planned Q OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use FacilityENi FORCEMENT StATOt'-. < <br /> V A HAULING AND MANIFEST REQUIREMENTS @ Notice Of Vtofetion . Q etEtst.:if)l <br /> 0 (a PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. i CPmpllOnce Deal ; <br /> 0 0 :PRC§42956-Registration/Decal in Vehicle I <br /> 0 ® 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ! Data <br /> 0 0 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB n , <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days l (Requited Por_NCL�dGi�l ���/ <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q;Refllrred GIWMB ERfd`fG61 % <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § <br /> Comments' Ip <br /> �v,, pJ ���t,vtvv 5 i�.1�,,45 v,.J� _ iV\ kC' <br /> _ 1 <br /> Inspection Form Included; Q �Q /�(/ <br /> Comments Included: Q - (✓c/ y — �-- v'-/,�. <br /> B sines er s Signature Phone umber spec�or's Signature Ph ne umber <br /> - - <br /> INSTRUCTIONS ON BACK InCtairect (� `J .J E }� fl MIP[L E 62os1 <br /> hite Copy:CIW Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> W <br />