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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of <br /> 18lgomla Survey Form - Page 1 1 3 - 1 0 1 3 2 5 0 <br /> CIWMB 181(New 04/04) <br /> Callfomia Integrated Waste Management Board <br /> Part A-S= BLUE OR BLACK INK PEN <br /> Business Profile . Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffbt: , -3 -,7 0 Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � O CHP Q CIWMB 0 Complaint O Educational Visit 0 Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Zca A dressiG1r�� <br /> Inspection Date � � � �� / � / <br /> " <br /> � <br /> Time In Time Out <br /> BusinessRep <br /> —Rep Title O AM Q AM <br /> �l crx"'W QPM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) tJ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ®Active ®Passenger ®Generator $Outdoor <br /> o Q Closed O Altered <br /> GPS Latitude - Q Hauler Q Indoor <br /> O O Inactive O Truck <br /> Longitude - 0 Planned Q OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer #Auto Repair Q Trucking Fleet 0 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 0 Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility , <br /> O O !PRC§42951-Waste Tire Hauler Registration and Transport of Tires ^•r P <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB r <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O C7 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers w <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q 1 Other: § <br /> CommentsQG'-7 r7 YF .-- �i[Xti� / • �., :J _ <br /> - - <br /> oq <br /> Inspection Form Included:Q <br /> Comments Included:0 - - - - <br /> Busine Rep's Ignature Phone Number Inspec r s ignature Phone Number <br /> INSTRUCTIONS ON BACK y� 62081 <br /> �t�k,� ,.�,� � � ihtt P;� E' 1 � 3 <br /> ® Y <br /> While Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0711604.0159 <br />