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r= Waste Tire Survey & Inspection Report Inspection Report Number <br /> staeo"arrorna Survey Form - Page 1 1 6 - Q 1 0 $ 0 4 <br /> CIWMB 181(Naw OM04) <br /> CalNomla Integrated W.W.Nanagement aoard <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> -- <br /> Business Profile Inspection Details <br /> TPID- n o� Inspection Type (Fill one) <br /> Site Suffix: , 3 S 9 1'1( 7 6 0 r .Routine Q Re-inspection 0 Referral 0 Obsenisdon <br /> Local N Referral,choose referral type(Fill one) <br /> Identifier: Lot- : � C Q CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name i� -- — <br /> nQ Inspected By Inspector <br /> T!�" 6.w - � <br /> Physical Address I{/ -3 Q / O <br /> Inspection Date O / D / D 7 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 0 PM 0 PM <br /> Operational Status .The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) n( (Fill one only) (Fill ail that apply) (FlII all that apply) (Fll ell altapply) <br /> `�' 0 Active O Passenger 9 Generator O Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0Inactive Q Truck <br /> Longitude - End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type.(Fill all that apply) <br /> O New Tire Dealer Q Auto Repair 0 Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer O Collection O Crumb Rubber /, �p <br /> O Service Station Q Hauler Q Agriculture Q Shredder Other ,14-1.9 AdA.W, <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> d Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O 14 CCR§18481-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 /> O O Other: § <br /> Comments �eG s�o ao1� P re lye."G' .ml.P �+Ye <br /> wor�C .Ca•zc l!�l�r Gl/a�r %t. <br /> Inspection Form Included:Q o'I) <br /> CommeN� <br /> r <br /> Bus 's S <br /> Phone Number Inspector's Signature Phone Number . <br /> INSTRUCTIONS ON BACK E X A IM P L E 1 2 3 62081 <br /> ■ 0716504.0036 White Copy.CM/MB Yellow Copy:Operator Pink Copy:LFA ® ■ <br />