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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State <br /> dCalifornia <br /> -'Survey Form - Page 1 1 3 - 1 0 2 5 7 1 3 <br /> CIWMa 181(New 04/04) <br /> CaliforniaIntegrated Waste Management Board ' <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection DaWis <br /> TPID- Inspection Type(Fill one) <br /> dP Routine Q Re-inspection Q Referral Q Observation:' <br /> Local If Referral,choose referral type(Fill one) <br /> Identillec: <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Outer <br /> Business or Facility Name <br /> y o c Inspected By Inspector <br /> I <br /> Pn sic �a <br /> 2 y 7 - �. <br /> _ <br /> Inspection Data <br /> q / <br /> Time In Time put <br /> Business Rep 1 Two O O AM <br /> O PMQ PM <br /> r <br /> o <br /> -- Ciprational Status Tiro Type: Buslneas Role Storage Type <br /> (Fill one only) FII ttt <br /> Tire Count(Whole/PTE) 2� ( I ._.. (FIN dithat apply) (Fill all that apply) <br /> Active t)Passenger ®Generator Q Outdoor <br /> GPS Latitude 0 Q Closed Q Altered <br /> 0 Q Inactive ®Truck 0 Hauler Q Indoor <br /> Longitude - - �Q Planned Q OTR 1 Q End-Use Container <br /> Buslness Type (Fill all that apply) — - - - - - - <br /> Q New Tire Dealer Q Auto Repair !Trucking Fleet Q Government Relreader <br /> Q Q Dismantler Q Tire Derived Fuel <br /> 1Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B—Inspection of Waste Tire Dealer,Generators Hauler and End-Use Facility <br /> Q 0 PRC§42951-Waste Tire Hauler Registration and Transportof Tires. <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-ManifestSystem Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 0 Other. § <br /> Comments <br /> Inspection Form Included:Q. <br /> Comments Included:Q _- h�' <br /> �rj 3 71jjBu ess epa Signal Phone Number I s _ Phone Number <br /> INSTRUCTIONS ON BACK 1 - ! 3 62081 <br /> 1gAIAWhite Copy.CRlVkIB Yellow Copy.operator Pink Copy LEA ® ■ <br /> '0526204.0685 <br />