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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> i= CWat'MB181of (14rnia Survey Form - Page 1 1 3 - 1 0 1 �+ 8 4 3 <br /> CIWMB 181 stew 04/04) <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: 1� D Al k 01 O ®Routine, Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) : <br /> Identifier: oth k Cp ,��,t Q CHP Q CIWMB Q Complaint Q.Educational Visit Q Other <br /> Business or Facility Name V i <br /> Inspected By Inspector <br /> Physical Address 3 t 1> �- �- ~ <br /> .ITT l V(`C�' � <br /> - <br /> S� Inspection Date C) <br /> Time In Time Out <br /> Business Rep Title 8 AM t '®AM <br /> 0P l Z 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (FII.all that apply) (Fill all that apply) <br /> ®Active ®Passenger ®Generator ®Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS Q HaulerQ 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 n �e <br /> . <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. " y <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§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 years `k + <br /> Q O <br /> 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 i <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. <br /> Q 1 Q 1 Other: § r .`I <br /> Comments Lvt�I•L 1 r � We, p A L�1`°L t`>Q S —Z"��O . <br /> f <br /> t lA Entere <br /> KS <br /> Inspection FormIncluded:O �9r� <br /> xo y.LfG✓ro _ s 3-��6�C <br /> Comments Included:Q -- <br /> BusinesWp'soWiginsture Phone Number Ins ctoes Signature Phone Number <br /> 1t� ,s '� 62081 <br /> INSTRUCTIONS ON BACKJAlMjPjLj6j IIIR131 <br /> ■ WhiteCopy CIWMB Yellow Copy:Operator P1nkCopy:LEA ■ <br /> 0529204. 1058 <br />