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= , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateof181(Nrnia Survey Form - Page 1 1 5 - 0 2 7 9 2 <br /> CIWMa 181(New 04104) <br /> California Integrated waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I inspection Details <br /> TPID- / � / Inspection Type (Fill one) <br /> Site Suffix: 2 �Q 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Ar 7:5 ,,,;n <br /> �14y 45 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name / Inspected By Inspector <br /> 5 <br /> Phys cal Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> QPM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> 1 .515 Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) tR l all that apply) (Fill all that apply) <br /> ' 0 Active 0 Passenger 0 Generator i 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude a Hauler 0 Indoor <br /> 0 0 Inactive �Truck <br /> Longitude _ 0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ew Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Govemment S Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility EN.. iNNT TATUS <br /> y- A; HAULING AND MANIFEST ROCUIREMfiNT8 rt� ' ►f VlotrttIofi 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Cgttlladll(ns <br /> 0 0 PRC§42956-Registfation/Decal in Vehicle .,f,; t <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and The Trip Logs within 90 days � � � , <br /> NOV or OM <br /> 0 0 !14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ? <br /> 0 0 i 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ,. .,triforcillingnt 1 <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities 4 <br /> O O --_ <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 1 ` <br /> g!I'�*IV,4 V647�lontt <br /> 00 Other: § <br /> Comments <br /> f J <br /> SI 42r, is G k-1Q_4k1e.1 Q f)luo- 4- <br /> Inspection Form Included: a <br /> Comments Included: g�e-7 <br /> B in a Rep' gnature Phone Number In Ctor's Signature Phone Number <br /> INSTRUCTIONS LCOtf4S31�t In> 3 r>1Et A A P � � j 62081 <br /> - I -� <br /> Entered White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> KB <br />