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Waste Tire Survey & Inspection Repork!aGnspection Report Number ■ <br /> State of California 'yr <br /> CIWMB 181(New 04/04) Survey Form - Pagel <br /> 1 ` 1 3 - 1 0 0 6 3 9 4 <br /> 011%mia Integrated Wast,Management Board Nov 2$ 2p05 <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 12 Z 0 9 U 1 Q Routine I®Re-inspection Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: � _�, CQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business <br /> or Facility Name Inspected By Inspector <br /> ` _�r c,e_5 _ •_� <br /> Physical Address ''-j 1 p •'"L` 65 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 4W AM Q AM <br /> PM O PM <br /> — Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE). (Fill one only) (Fill all that apply) (Fill ail that apply) (Fill all that apply) <br /> 0 Active ®Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 40 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility k <br /> 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 /> O O < <br /> 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 a ` <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years .t-K = <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 r 3.y x <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments <br /> p � b,— ��•ss --�'ir��. •K ' :��/fr�_cr�'><— _GTL-5 <br /> r.(sM[ �.G:PIViv�c ``�11r/'Lc <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Bus ess Rep's Signature Phone Number In; clot's Signature Phone Number <br /> INSTRUCTIONS ON BACK A ��t ICTK M P 62081 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> F1i l_1 r,4�1-}, <br />