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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State aC1°� ClWM 181California Survey Form - Page 1 I 5 - 4 <br /> CVWMB 181(New 04104)my <br /> California Integrated Wast©Management Board <br /> 7 13 <br /> Part A- Survey _ _ --__ BLUE OR BLACK INK PEN <br /> Business Profile - - Inspection Details - - --- -_ � <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t '"l V 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 Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> r <br /> Physical Addret "ss �A - p <br /> k 6o <br /> Inspection Date <br /> Time In Time Out1 -\ <br /> Business Rep Title O AM O AM <br /> O PM O PM� <br /> U- — -- �� - --- Operational Status Tire Type l 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> Q 0 Inactive 0Truck <br /> Longitude _ �- - 0 Planned �� OTR 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 5"'P. <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityFARM / <br /> .r; '�4 ..�.y=-ri,�a,- - ;/.• —., :u%%J 0 <br /> MEM <br /> %%':'/ ✓%Yj'ill/�% !' ./ !i :�:i/'�r�i%- �:r �i �,' <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal In Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program II]Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days /r r ✓/' r/�'��' <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> r <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 <br /> 0 Other: § <br /> Comments Ate- o-0 <br /> 1 <br /> - — <br /> Inspection Form Included: © <br /> Comments Included: - - <br /> 0 Bu ness ep's Sig P one be-rIns ector's Signatur Phone Number_ ., <br /> 620£11 <br /> INSTRUCTIONS ON BACK rNt P G JEJ 1112 <br /> White Copy:CIWM Yellow Copy:Operator Pink Copy:LEA <br />