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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of.r <br /> CIWMB <br /> Survey Form - Page 1 I Q - 1 0 1 0 6 9 $ <br /> CIWMB 181 thew 84/04) <br /> California Integrated Waste Management Board <br /> Part A-Surve _ BLUE OR-BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID Sites I - O Inspection Type (Fill one) <br /> Site Suffix: `T <br /> 0Routine QRe-inspection QReferral <br /> Q Observation <br /> LocalA1 Referral,choose referral type(Fill one) <br /> Identifier: , ( J)7,(�(77w H Q CHP QCIWMB Q Complaint Q Other <br /> Business or Facility Name ompEducational Visit Q-- <br /> I I ,a_J_, Rk`��/ �G Inspected By Inspector <br /> Physical Address 39 - / 0 <br /> LoO l (?Aq5d,`�o Inspection Date a C.f 1 l / Q 7 <br /> Time InTime Out <br /> Business Rep Title Q AM O AM <br /> PM O PM <br /> Operational Status, Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> r r Active 0 Passenger g Q Generator Q Outdoor <br /> GPS t-atltude <br /> O Closed O Aftered <br /> ®Hauler Q Indoor <br /> O O Inactive Q Truck <br /> Longitude - O Planned *OTR O End-Use Q Container <br /> I _ <br /> Business Type (Fill all that appy) — <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet O Government O Retreader Q Dlsmantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder ®Other I riGteI ra Rso�)ts f a/LtjulS <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facltity <br /> O O PRC§42951-Waste Tire Hauler Registration and Transporl of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O 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 /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 1010 1 Other: § <br /> CommentsRoull"imf CGT 7�1.`��j��C r?�Da <br /> rwains l di4t in *e as ✓ )A a 41A rd �r <br /> Ji e. Wau a wr, cft' L S <br /> lfreS On g_. n0,� 1 �i/10 id7► <br /> Inspection Form Included:Q j��fJ� �� �/' Za'1 <br /> Comments Included:Q A <br /> BusinessRe ' Signaturephone Number Inspedys S n uro Phone Number <br /> ■ INSTRUCTIONS ON BACKx A TA p L��3 82081 <br /> 0716504.0016 White Copy..CnNMB Yellow Copy.Operator Pink Copy..LEA © ■ <br />