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Waste Tire SL fey & Inspection Report Inspection Report Number <br /> StatCIWMB <br /> California Survey Form Page 1 I - D Q 6 3 3 2 <br /> CIWMBB 181(New 04104) � <br /> California Integrated Waste Management Board <br /> Part-A- Survey- _- _ ._ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details —� <br /> 7PID- Inspection� � � � _� _ D I Inspection Type (Fill one) <br /> f <br /> Site Suffix: Q Routine Q Re-inspection Q Referral ® Observation <br /> Localr[�/ If Referral,choose referral type(Fill one) <br /> Identifier: � +aJ l/�►" -y 1—Hl� ) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Y <br /> Inspected By_ Inspector <br /> sical A <br /> Phyddress l d �ip��es <br /> Inspection date <br /> Time In Time Out <br /> Business Rep Title / AM &AM <br /> O PM ' 0 O PM <br /> - - 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 /> I Active Passenger ® Generator 9 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® 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 /> V. ��� ����ANR iVI�;�tlt�SfiR��}t11RE�IC�4°I'S � NO� <br /> I0 PRC§42951 -Waste Tire Hauler Registration and Transport of TiresIM <br /> PRC§42953 Contracts with Registered Waste Tire Haulers. �y ! �/� ✓ Y�f/i, <br /> /iii <br /> Q Q PRC§42956-Regis trat!on/Deca I in Vehicle <br /> O O 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 O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Tri Logs within 90 days /~ / tj <br /> � <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> �,. iii,:r, /i�,',;,/-,;gni/.✓� �i a� �%/�� <br /> 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O i Q Other: <br /> Comments �`aV <'a�>C�� _pfG /� 1(rfc2��lta `�G'P.r�'✓ 5� 97%C�5) <br /> �rG�p- f er.�,�,r�e�j �fp(�rvx;, <br /> 1 - L)e, racLQ�_ dfC� !/SGT' �r`.o2' <br /> Inspection Form Included: Q <br /> Comments Included: Q - --- --- - -- - - <br /> Business Rep's Signature Phone Number Ins p or's Sig ature - - Phone_Number <br /> 62081 <br /> INSTRUCTIONS ON BACKr ,. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />