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« , Waste Tire Survey & Inspection Report Inspection Report NumberS'a ■ <br /> r CIWMBto 181Cal(New <br /> Survey Form - Page 1 i 2 - 1 Q 0 6 4 1 <br /> CIWMB 181 stew nage <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection D Q - © ( Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CIWMB CHP Q <br /> Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � Inspected By Inspector <br /> Physical Address <br /> q4Lf I\j �P <br /> Le � //�� C� inspection Date Z / •7 <br /> ")AL C�T`i {�� <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> n /� Q PM Q PM <br /> c� /—y�tr — ® tghgq 0-- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t ' -Z a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger *Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned ®OTR Q End-Use ®Container <br /> _ I <br /> Business Type (Fill all that apply) <br /> Q 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 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other L� �l <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facilitytt1+ MiTAfit <br /> PRC 42951-Waste Tire Hauler Fs <br /> . `'. •` �{""� '� <br /> Notice Of Violtrtton (�Extension <br /> Q Q § Registration and Transport of Tires <br /> PRC§Q 42953-Contracts with Registered Waste Tire Haulers.Q Gornpltarice Deadline <br /> PRC e Q42956-Registration/Decal in VehicI <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 /> x <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 f �: <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 / ` S — f' L4 5.n42,, ,•Gr, CI LJM 8— Zo L+r_�vr A&411. CrW* 0� <br /> ft) 1,.)!Z L.J i( 1 D l_ -! 1 rra oti> i -Ft, <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Busfiftss Rep's Signature Phone NumberInspe 'sS _ Phone Number <br /> ■ INSTRUCTIONS ON BACK X P 8 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />