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Waste Tire Survey & Inspection Report Inspection Report Number <br /> StatCIWMB <br /> B 81(New Survey Form Page 1 1 l 01 3 2 8 7 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Ins ection Details <br /> TPID- j /1 _ D ! Inspection Type (Fill one) <br /> Site Suffix: `1 / ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Scuo_ <br /> Identifier: 106 C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B - Ins -- <br /> P Y Inspector <br /> p <br /> �ifcti $res TY"ck`� 3 °i - l e Fyz�se- <br /> A <br /> Physical Address <br /> el <br /> en� h Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM - PM <br /> - <br /> 1Yf ---- - Operational Status Tire Type Business Role r Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) I (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 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 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 Q Other - <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 Q I Other. § µ 1_JA _{ I <br /> Comments � V�.Q �� Fl & r-oWy l IS n-6 -/on <br /> e <br /> -Ara --af. i5 aGt°SS �tibDi _ gs ii�trnrn - e - <br /> - � D� C�2 ✓��l(T7.cS� OCC _ � <br /> Inspection Form Included: QI <br /> Comments Included: 0. - -- - - -- - - <br /> Business Rep's Signature Phone Number ns ctor's SWature _— Phone Number <br /> INSTRUCTIONS ON BACK {t i' jjjNjMjE1XjAjM.jPjLjE1j1 213 62081 — <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0723504. 0098 <br />