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ciy <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State n/Callfornla <br /> CIWMB 181(Now 04f04) Survey Form - Page 1 1 4 - 1 41 4 8 8 5 <br /> Callfornla Intograted Waste Management Board <br /> Part A-Survey __. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details -- <br /> Business <br /> - Inspection Type (Fill one) <br /> Site Suffix: 3 C> 7 - (10Routine Q Re-inspection Q Referral Q Observation ' <br /> Local if Referral,choose referral type(Fill one) <br /> Identifier: T. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busine/s�s orrfF,a_ciifty Name ] Inspected By Inspector I <br /> f~f1�1IUn'A; t Ori •�-S 'r'^ G /J C3 - 1 / �,� ��t�C �S I <br /> Phy tcal Address / l <br /> Inspection Date I Z' Z I C) S <br /> Time In Time Out <br /> Business Rep )Crw_t � Title <br /> i O AM Q AM <br /> i✓�-�1a3 w+q�' %t CC�.�' tb� O PM _ QPM <br /> — _ -� --- Operational Status, Tire Type J Business Role storage Type <br /> Tire Count(Whole/PTE) f(Fill one only) (Fill all that apply)1. (Fill all that apply) (Fill all that apply)' <br /> 0 Active Q Passenger Generator Outdoor <br /> C Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> � O Q inactive S 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 0 Trucking Fleet Q Government Q Retreader Q Dismantier 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 /> /%/.�.�.✓i/i//.n� <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> iRegistered Waste Tire Haulers. <br /> Q I Q PRC§42953-Contracts with <br /> Q I Q f PRC§42956 Registration/Decal In Vehicle <br /> QjQ <br /> 14 CCR§18459 -Responsible Entitles Complying with Manifesting Requirements <br /> Q (� 14 CCR§18459,1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 ' Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q II 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 /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q I Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q I Q Other: § / <br /> Comments ' <br /> Inspection Form Included: 0 _ <br /> Comments Included:t� — — — -- — — L - `G v�-' -, <br /> Bus' s 's ur Phone Number Ins is Igna ur_ Phone Number <br /> P .L � Y3 62081 <br /> INSTRUCTIONS ON B CK P / Aj <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />