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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Rategted asteNi Survey Form - Page 1 1 9 1 0 1 3 6 3 6 <br /> CIWMa 181(Naw 04!04) <br /> CalMomia Integrated Weate Managerrrent Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details _ _ _ <br /> Inspection Type (Fill one) <br /> Bite suffil y 3 0 ,2 s - <br /> 0 Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier �LZlL C/A2 �!1 0 CHP Q CIWMB ( Complaint Q Educational Visit Q Other <br /> Business or Facility Nemo <br /> Inspected By, <br /> PeInspector <br /> /, 9 U <br /> Physical ddress /- � 3 - / O / <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title <br /> O `� �AM � D 2 G• ®AM <br /> �_ J O PM / f O PM <br /> - Operadonal status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) (FIB one only) (Fillall that apply) (Fill all that apply) (Fill all that apply) <br /> t t 0 Active Q Passenger 0 Generator 0 --.---. <br /> DQ Closed O Altered '� <br /> GPS LANh'de 0 Hauler O Indoor <br /> O 0 Inactive &Truck <br /> Longitude - 0 Planned Q OTR Q End-Use O Container <br /> Business Type (Fill all that apply) - <br /> Q New Tire Dealer p Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection 0 Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder OtherP�/ l �r�cc�p <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registratlon and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O 0. PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> to 10 1 Other. § <br /> Comments <br /> done <br /> Inspection Fonn Included:O .-. <br /> Comments Included:Q �_� /� ��+� C-O17 <br /> _-- BSt_Inssa Rep'tt Signature _ Phone Number Inspectoft Signature __ — Phone Number <br /> ■ INSTRUCTIONS ON BACK E X A Nit P LjgL112131 62081 <br /> White Copy.CIWMS Yellow._Copy:Operator Pink Copy:LEA ® ■ <br /> l 19404.0043 <br />