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■ �_ , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB181 <br /> astewOMge Survey Form Page 1 1 2 1 01 0 7 4 2 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile. Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> site suffix: I 0 5 v O Routine Q Re-inspection Q Referral Q Observation <br /> Local / _ �� If Referral,choose referral type(Fill one) <br /> Identifier: [`/vY)W�•L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> Physical Address <br /> Inspection Date O S a <br /> Stock CA q g�3 r <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> �h c) ��( r 0 PM 0 PM <br /> Yf y 4 f y ylnl ( LW ~v 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 /> Active 0 Passenger •Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR O End-Use ®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 — ID Other Colima L4 + <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility �r <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires r <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle Y <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 yearsx- <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers . <br /> O O <br /> 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 /> 1010 Other. § <br /> Comments 1 Laft < ` e rrwfed Az <br /> ` s �` TiYG �fZYe r iee_ eLbT <br /> M L <br /> #7ajqvqACc 'sent <br /> Ido 01 4ens <br /> Inspection Form Include r/ _2 r1.71.0(y -/WO —77&t0 <br /> Comments Included: - --- '7 <br /> Busine p s Signa ur_e_ Phone Number Ifisithetoes ElIg4ature- Phone Number <br /> INSTRUCTIONS ON BACK X A P'L E 111213 62081 <br /> 9716594.0112 While Copy.CIWMB YcilowCopy:Operator Pink Copy:LEA <br />