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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State WMB California Survey Form - Page 1 1 6 1 0 1 3 1 5 4 <br /> CIWMB 181(New 04/04) <br /> California Intel Waate Manayement Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - <br /> TPID- D �j / Q - O Inspection Type (Fill one) <br /> Site Suffix: / D t( 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local N d� Referral,choose referral type one) <br /> Identifier: ���-ti��y Q CHP Q CIWMB Q Complaint <br /> laint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> r^-r <br /> Physical Address 3 sLL1,�av!'Y�~�r/� <br /> I -- <br /> 9 j`'^� Inspection Date Q Q 7 <br /> �� Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t e /1 /� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> !1 [/ Active Passenger 6 Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q 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 /> 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 /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires, <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <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§184592.1-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 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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments el <br /> rP,' 74>y_ ' <br /> y/C�dt. /rtc de. /�pDa rm�► . o?�t9 d yc�/u�4 Y4- owl �S <br /> a-,e �7�. Ai� i s /j,�o�+tai. /t/o' e- hG� '0-- <br /> Inspection Form Included:Q9/A�6Ill <br /> Comments Included:Q <br /> Business Re s Signature Phone Number Inspector's Signature>- Phone Number. <br /> INSTRUCTIONS ON BACK ,II � lE) ,p p L. E,_ 1 2 S 62081 <br /> ■ W Bite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0705904.0350 <br />