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II, <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> rr BtaleolCal(New Survey Form - Page 1 1 8 1 0 1 3 4 7 8 <br /> CIWMB 181(New 04W1 <br /> celNomie Integreted Wei Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details--- <br /> TPID- / O 7 / - D I Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection O Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier S4.02- v�Qgt e..�/1 O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Kddress 39BU?lY�l�jy,4 <br /> AOL <br /> Inspection Date D _5 Q Q 6 <br /> Time In Time Out <br /> Business Rep - ---- -- - Title Q O AM <br /> cllDa zske� ' oL / a2— [� L0 PM 6 O OAPmmOperational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r 0 Active 9 Passenger ,Generator •Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive Q Truck <br /> Longitude - O Planned O OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government C�Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§16459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 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 /> Q Q 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 Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 1010 1 Other: § <br /> Comments � ,ate fh,ssaa�,srn s day auae q/4k01 <br /> ko : <br /> /'c wed P.v q ,o w ezAf pi-10 <br /> !`e ��. 70 �./ �v 'r a,, �>,roc. �%a ✓�B-r!�S�, .. <br /> Inspection Form Included:Q �� /�(! _ N,,,��� ����1�1� .�6✓'G 76�-r�3� <br /> Comments Included:Q _/7 <br /> BYsi sa Rep's 8lpnfture Phone Num er Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILFEP 112131 62081 <br /> ■ White copy.cwms Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 1117904.4_14 16 <br />