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Waste Tire Survey& Inspection Report Inspection Report NumberState ■ <br /> C1WM 181(California Survey form - Page 1 i 7 - 0 1 0 r <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> 14 <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` j_ Inspection Type (Fill one) <br /> Site Suffix: / 4 3 C.1 tI! a '� ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address z '( <br /> 6 5J� ) lye <br /> ^� Inspection Date' 1 /l�' Time In Time Out <br /> Business Rep Titlle�� t /�ff 0 AM Q AM <br /> h Q e� aS . / ' �, O PM 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) (Fill all that apply) <br /> v 0 'SI4.e+. Q Passenger Q Generator Q Outdoor <br /> D *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 ®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 Collection Q Crumb Rubber <br /> 0 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 /> O 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 O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> .t <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 4 <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities v< • <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 'v'f <br /> Q Q Other°§ <br /> Comments f iz� d1us <br /> (A) -tVeS . NO <br /> Inspection FormIncluded:QJ ?q- <br /> �aa � <br /> Comments Included:Q <br /> Business RSignature Phone Number Insp tor' Sig to Phone Number <br /> INSTRUCTIONS ON BACK ;AII p IL 62081 <br /> ■ <br /> 0716564.0108 ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />