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Waste Tire St Bey & Inspection Repor Inspection Report Number <br /> State of gratedVlastrnla Survey Form Page 1 1 8 - 1 0 0 0 3 3 3 <br /> CIWMB 181(New 04104) � <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: , 0 3 ( Q Routine Q Ro-inspection Q Referral ® Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: s 7q Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1� <br /> Inspected By Inspector <br /> ,Q <br /> i <br /> Physical Address <br /> Inspection Date S7 <br /> '[ Time In Time Out <br /> Business Rep Title © D SAM I t ; 5; q <br /> AM <br /> 0 PM / 0 PM <br /> Operational Status; Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ®Passenger ® Generator I* Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude • Hauler Q Indoor <br /> D Q Inactive ', Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Buslness Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Tricking 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 FacilityUS*V111 0 <br /> �i � ,l" � "", �1.'?� ♦♦,./i .:/j/6/<j�Y/%G�iri'r%/ ✓,/% i / // �/. <br /> QPRC 42951 -Waste Tire Hauler Registration and Transport of Tires <br /> § 9 p 'ry /i/i /// /• ///fir y%'//,i r i <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. ,�j//r� <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 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 /> 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 l , iii/ %// ♦ / <br /> Q 0 <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tiro Generators <br /> Q 1 Q Other; §§^^ /� ) <br /> Comments L �.� 9/7�2_dS <br /> ny <br /> _ 1 <br /> Inspection Form Included: Q <br /> Comments Included: Q — <br /> Business Rep's Signature Phone Number I actor's Ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK -( ' �G.„ �, E% AMP L <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />