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; r Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CrWMf181(New Survey Form - Page 1 1 1 - 1 01 3 5 4 6 <br /> CNJMe 181(New 04!04) <br /> Celiforala Integrated Waste Management Board <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile -- -- Inspection Details - - -- - -- - <br /> TPID_ Inspeetion Type (Fill one) <br /> Site Suffix: ` y �J_ G} O ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local f� ! If Referral,choose referral type(Fill one) <br /> Identifier: J r 19� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name v Lr <br /> �� Inspected By Inspector <br /> Physi( Address 51 <br /> Inspection Date <br /> 07 / <br /> G O <br /> �r Gla �52�10 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> C� 0 Active ®Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ®Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) - - - <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> ak _ <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires g <br /> 0 <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. ',,����,T•<.'•, , <br /> 0 0 PRC§42956-Registration/Decal in Vehicle "3 <br /> 0 <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0a;r,< <br /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days I ��`} - � •,: `�a`,� <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years i d, <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators a <br /> 0 1 0 Other: § <br /> Comments I <br /> c _ <br /> Inspection Form Included:0 <br /> Comments Included:0lof!!f:;[_/ <br /> Business Rep's Signature Phone Number o's S gna a Phone Number <br /> INSTRUCTIONS ON BACK 111MMIEKAIMIPILIE1 1112N62081 <br /> ■ White Copy.CIWMB YeIIOW Copy.operator Pink Copy.LEA ® ■ <br /> 0522104.0005 <br />