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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 ( 1 - 01001"' 18 <br /> CIWMB 181(New04104) <br /> CalMomla Integrated Waste Managenage <br /> ment Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection O Inspection Type (Fill one) <br /> Site Suffix: (� VRoutine Q Re-inspection Q Referral Q Observation <br /> Localr If Referral,choose referral type(Fill one) <br /> Identifier: �A �J o yzy'1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � Inspected By Inspector <br /> �� ��4 <br /> Physics ddressp� J " �y'v vw r �-4vVI A _ / o / <br /> loolo, <br /> Rr(?i,tcC1` Cam C4 '7523 Inspection Date Q 2 / <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> r o PM o PM <br /> —- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 6- 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ir Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS LatitudeQ Hauler Q Indoor <br /> O Q Inactive a Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill ell that apply) - - <br /> Q New Tire Dealer Q 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 Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other 1/d <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility :. - <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle •^ <br /> Q Q 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 /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q ® 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q 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 /> 10101 Other: § U <br /> Comments )(lft <br /> ` - <br /> A S e`7;k„ )/ Az 1j <br /> ed;C9L nn <br /> to— in�'o� V•eYv w <br /> Inspection Form Included: �btg <br /> Comments Included -U•FJ L/I <br /> :<J- <br /> need Rip's Signature Phone Number IaturePhone Number <br /> INSTRUCTIONS ON BACK11 i' EX <br /> jjAJMjPjL1Ej j ,2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0702104.0097 <br />