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i Waste Tire Survey & Inspection Report Inspection Report Number <br /> Sgratedate of astenia Survey Form - Page 1 1 1 . 1 0 0 8 0 8 3 <br /> CIWMB 181(New 04!04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile 11 Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0Routine Q Re-inspection Q Referral Q Observation <br /> i Local If Referral,choose referral type(Fill one) <br /> Identifier: p J r CA'%.- �h�y O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I <br /> Inspected By Inspector <br /> P slca Ad <br /> to C <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep ) / Title O AM O AM <br /> 0 PM QPM <br /> r <br /> Operational Status i Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill ail that apply) (H)l all that apply) (Fill all that apply) <br /> Q Active Q Passenger ® Generator Q Outdoor <br /> Latitude O O Closed Q Altered <br /> GPS O Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - � Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) l <br /> Q New Tire Dealer • Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Deafer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other 4 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFq_RCEMENT.STAT <br /> :V A HAULING AND MANIFEST REQUIREMENTS <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O.Ngt{es of VEnlatlotl (� �Xt�tlsltitl <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Dsptilllle <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting RequirementsDato / <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O ; 0 (Ri�quh9d tgrNt�VorX� ` <br /> 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 v n' <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O:I � <br /> 14 CCR§18461 -Manifest System Requirements or Waste re End-Use Facilities <br /> _140.0!` >i3yfM /�f �ft'n <br /> 1 O ' MiRifWTiEdUFliti <br /> 14 CCR§ 18462-Manifest System Requirements for Tiro Dealers or Waste Tiro Generators <br /> 010 �~ <br /> Other: § <br /> Comments . <br /> / /� � ) / 1 [ !h25 ctv. t JCaI�f � <br /> --h r4L' �l „ -�--+� TL.�- [Aw1/14y �aof:�v�S 'Tr-> <br /> #'I rig C'.7 D�c�1 r U 1 1 r`L- �/`�t�✓-r.r-- (-1-..�` iJ1+.�H•-bG�r' ct r�cel 1.15� c� <br /> rec,k,I v�e_ kwL v, er- 'i — t�r-�U�'� Wr s f� �'1►^PrS .. <br /> Inspection Form Included: Q <br /> Comments Included:0 a/ 5 <br /> Business Rep's Signature Phone Number,/ r s Signa Phone Number <br /> INSTRUCTIONS ON BACK Cor t _{ttcgrrt; ( .tvv1; � t AAAA�PPTL LE jZ3� 62081 <br /> While Cop :GIWM Yellow Copy.Operator Pink Copy:LEA <br />