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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWMB <br /> t81(New Survey Form - Page 1 - Q 1 0 fi 7 0 <br /> CIWMB 181(New nage <br /> CalHomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- D Inspection Type (Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � 1c, — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Physical Address <br /> �� ( 9sa1/0 Inspection Date p y / g / Q <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> & r4 n, 0 PM 0 PM <br /> Ci(lL( r►s huh asdy.sltaJ !�1�� <br /> Operational StatusThe Type ' Business Role Storage Type <br /> Tire Count(Whole/PTE) t e 1 n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 d- ®Active ®Passenger ®Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude - Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 ®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: § f/ I 1� /f ;� <br /> Comments/Z - -O . ( �+'tW G .Ly .*f_ !� was )IO/SLC 1/iKs <br /> a IOWlAIV mer/_4 <br /> a; or o� was-t -hY'cs, L¢s $chw is_ across .,,Vee-t ar1d__✓ (cs <br /> tie _�erV`�.d , ;� r►eeded.lire �vtac,�urles on bwt nab �urr&dl� - r,Ll. <br /> CTL A'WL Y'e Fevwx-e , 'cc,_sled. Vec�r cwft] cis ccs s�. Dvo ✓i o l a'hit-c�h><.IW <br /> Inspection Form Included:Q <br /> Comments Included: <br /> Bu ness Rep's g gnature Phone Number In or. Si acre Phone Number <br /> INSTRUCTIONS ON BACK IEjXIA1MIP1LIE1 1112131 62081 <br /> ■ 0716504.0066 White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ■ <br />