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■ L'y11 Waste Tire Survey & Inspection Report Inspection Report Number <br /> State IWMB181(Nrnle Survey Form - Page 1 I - 1 0 0 8 0 8 7 <br /> CIWMB 1B1(New04f04) <br /> California Integrated Waste Management Board <br /> Part A-Survey u —_ BLUE OR BLACK INK PEN_ <br /> i3uslness__ProAle Inspection Details <br /> TPID- Q Inspection Type (Fill one) <br /> Site Suffix: , -- p rj (7 O C Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local tf Referral,choose referral type(Fill one) <br /> Identifier: 10 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Butsivvn��ess orFacility Name Inspected By Inspector <br /> PhysicalAddress <br /> 41-& <br /> cv <br /> Inspection Datep n A <br /> CAr `tf3*5L <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> - -- - -- - Operational Status Tire Type Business Role f Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (F)JI all that apply) (Fill all that apply). (Fill all that apply) <br /> t b Active Passenger Generator <br /> ® ® 9 � ®Outdoor <br /> - -- -- -- ---- -- ---~0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude Q Planned Lo OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) _ - -- - - -- - - -- - _-- <br /> 0 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 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other <br /> v t <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ' %%16 Mom <br /> �, <br /> Q Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires / %f:• j��, / <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. / �' % /''•j i , <br /> Q Q PRC§42956-Registration/Decal In Vehicle - <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements V <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-The 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 /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities i <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 o Other; § <br /> Comments <br /> Inspection Form Included: Q <br /> OIL S� <br /> Comments Included:.Q <br /> L -- - —.Busine Signatu Phone Number _ In actor's Igna ure Phone Number_ <br /> 62051 <br /> INSTRUCTIONS ON B C / Eye AIV P L E 2 3 <br /> White Copy:CIWM Yellow Copy:Operator Pink Copy:LEA <br />