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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State B181(Nof mta Survey Form - Page 1 1 9 - 01 4 8 9 8 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �.►+ If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> A11:4-4- <br /> Inspection Date Q I `'7 C C <br /> Time In Time Out <br /> Business Rep Title Q AM Q AAA <br /> QPM 0 P <br /> ( t� Operational Status' Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f f 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> C 0 Closed 0 Altered <br /> Latitude <br /> GPS 0 Hauler 0 Indoor <br /> p 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityNF4R :EMNT.STATUS_._.�__..._, <br /> ttA _ 4 A �M�AIs RtQ. ItItMi ' <br /> 0 ' 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Matln�Off.Vlpla~flan 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Cannpal� Ig ppadlltle <br /> 0 0 PRC§42956-Registration/Decal in Vehicle ! <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements m <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (ReQ4frt�a 1orN0V-QrEXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> I <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0A.- 'OlitltMllt <br /> 0 0 14 CCR§ 18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators / %:/ir/ s r, <br /> 0 0 Other: § fnm <br /> � >. <br /> _..._ <br /> Comments ft`oa " C,I:.�._ 1 gcXrX►, 5 _ <br /> Inspection Form Included: 0 <br /> Comments Included: 0 ` <br /> Buslne ,s lgnatu Phone Number In is Signature Phone Number <br /> F <br /> _ P � �' T1 <br /> 62081 <br /> f 2 3INSTRUCTIONS ON BACK MOW* <br /> IN <br /> White Copy:CIWMB <br /> Yellow Copy:Operator Pink Copy:LEA © ■ <br />