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=1s= Waste Tire Survey & Inspection Report Inspection Report Number <br /> State�= ClWM f181(NCalifornia Survey Form - Page 1 7 - -d 0 4 <br /> I' CIWMB 181 stew nage <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 y - Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. SA-h �a q �,,� �j t,n,v Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U <br /> Inspected By Inspector <br /> Physical <br /> (Add ss <br /> 1 Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> �t �e...beela�L r-♦ l Z 0 PM C v ®PM <br /> - <br /> Operational Status Tire Type Business Role Storage Type: <br /> Tire Count(W holelPTE) o ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill,all that apply) <br /> Z ®Active Passenger ®Generator ®Outdoor <br /> Latitude <br /> O Q Closed Q Altered <br /> GPS O Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use. Q Container <br /> Buslness Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment Q Retreader Q Dismanter 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 /> DARWME MIN <br /> 13�r� x <br /> � a � k <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires I 4 s <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956.-Registration/Decal in Vehicle q <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements 4 <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 1F' <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 iyM1 Y, <br /> .• . ` : <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> •� <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O other <br /> Comments <br /> Wnn r L.� S 'vt c� <br /> t`1r�ai t��r�a� <br /> CX L awe ow. ed <br /> Inspection FormIncluded:,Q �" KS <br /> r � J C�V` `2 <br /> Comments Included:Q <br /> Hess Rep'szw6vure ne Number nspector's Signature Phone Number <br /> fi. r. 62081 <br /> INSTRUCTIONS ON BACK C%rre�t1lGPtk4'G IM P 2n <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0524204. 1081 <br />