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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State f California <br /> CIWM Survey Form - Page 1 I $ - 1 0 1 4 $ 0 7 <br /> CIWMB 18181(Now 04/04) <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile 1 Inspection Details <br /> TPID- _ O Inspection Type (Fill one) <br /> Site Suffix: l 6 .5 4'j Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J p �� _.Q� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> k Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> l 7( <br /> Inspection Date Z) <br /> Time In Time Out <br /> Businessr <br /> Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whoie/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f i Active Q Passenger Q Generator Q Outdoor <br /> C ; Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck i <br /> Longitude — Q Planned Q OTR O End-Use Q Container <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 Q Coliction Q Crumb Rubber <br /> Q Service Station Q Hauler Agriculture "O' h*der Q Other <br /> I <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility VS <br /> Q Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires � �@( Ibrt Q nstlon <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers.' <br /> O Q PRC§42956-Registration/Decal in Vehicle - <br /> Q O 14 CCR§18459 -Responsible Entitles Complying with Manifesting Requirements ' J <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O '/' sfgr NYbr = <br /> 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 Fr <br /> Q 1 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use FacilitiesX. <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> •a <br /> O O Other § <br /> Comments'11 <br /> _%e4_e_ wl�crr_ <br /> Inspection Form Included: Q / <br /> Comments Included: <br /> Business Rep's Signature Pho�ie Number a Signature Phone Number <br /> ...; �r 62081 <br /> INSTRUCTIONS ON BACK t s A P I I-I rlf 2 3 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />