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r47 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 1 1 • 1 01 3 31 <br /> CIWMB 181 to Mm <br /> I04104) <br /> Califomla Integraletl Waste Manageent Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 37j O j ®Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier. r�y O CNP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name •_x� �i n iJ Inspected By Inspector <br /> Pial � <br /> Phys%s�-f 1LH/C ;- G _ <br /> e C Inspection Date 03 J 5 0 G <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> —- 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> 0 ®Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 O Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler O 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 ; <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tireso, - <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in VehiclesY 'a <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements " <br /> O O 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 /> 00 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O a.; <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities ` <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O <br /> Other: § <br /> Comments , kis , -- — <br /> Inspection Form Included:Q <br /> Comments Included: - �`-s - �Z <br /> Business Rep's Sig ature Phone Number Ins tors Sfgnature Phone Wumber <br /> EN 62081 <br /> ■ INSTRUCTIONS ON BACK Y, � g E=X A F'L E �. 3 ® ■ <br /> While Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA <br /> 0611864.1=1174 <br />