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-f , Waste Tire Survey & Inspection Report Inspection Report Number <br /> ,r State ofCalifM Survey Form - Page 1 f 4 1 01 3 2 8 4 <br /> CIWMB 181(New 04104) <br /> Califomle Mtep2ted Waste 1,Management Board <br /> Part A-Surve _ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ! r - O I Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Is Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SNITo � as 0 QCHP Q <br /> CIWMB QCom Complaint <br /> Q E,ducational Visit Qp <br /> Other <br /> Business or Facility Name <br /> `J Inspected BY Inspector <br /> Phys0ju1_ wD6b_e j ' <br /> ical Address O eN6 , <br /> qt 9j <br /> •` <br /> S*`�,j., p (�� O/U Inspection Date 0 / / S / <br /> 1 V lI Time In u Time Out <br /> Business Rep <br /> Title O AM <br /> Ra /IM AM <br /> 0 P 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire CoUnt(Whole/PTE) 'D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger Q Q g Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O ®Inactive Q Truck i <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 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 7'-j^aU'0 r-® Aa�S <br /> LOService Station Q Hauler Q Agriculture Q Shredder Other L)iS )bU i on G�lardd h� <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q 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 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 /> Q 1 Q 'Other: § <br /> Comments I(nQ ?('�JK3LC/I CU Y?o QS axe �✓{�l J7J�K 1.C1-- o <br /> cussed 0-F& i'ePR w4, ( 4 0 ,t c s "Is�tss�o�� <br /> /V0 <br /> Inspection FormIncluded:Q <br /> i <br /> Comments Included:Q - _ _ _ <br /> Bus ass Rep's Signature Phone Number actor's I nat a Pone umbeh <br /> "a 62081 <br /> INSTRUCTIONS ON BACK Vr s a - q p ,a © ■ <br /> 'Nhde Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA <br /> V_t f 1':47A4, L_i V 1 4 <br />