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Waste Tire Sufty & Inspection Reportolnspection Report Number . <br /> ,,. State of WMB11(Noia Survey Form - Page 1 i 2 • 1 4 8 <br /> CIMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> _Business Profile I Inspection Details <br /> TPID- 3 6c R Inspection Type (Fill one) <br /> Site <br /> Site Suffix: * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ,0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> �� inspected By Inspector <br /> Ph s cal Address <br /> Inspection Date <br /> Time In Time Out7 <br /> Business Rep Title O AM O AM <br /> 0 PM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude O (0 Closed 0 Altered <br /> GPS 0 Hauler 0 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 a Agriculture 0 Shredder 0 Other L <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCE MTSTATIS _,� <br /> Vt A I HAt1LING AND MANIFEST REQUIREMENTS Q Notlae Qf.Vl+ila#Iran. 06,444Sl44 <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Cprppll;91Ec0 I) a'tllfg$ <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Data <br /> 0 0 14 CCR§ 18453.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Rar{yrt$ f9lnf *1 ?CTj <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years H " <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Ai ' <br /> 0 0 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § <br /> J <br /> Comments ��! �. C.�� �1?`T� �-�!/�il�gCL• `[ f Y`�� G) �"' --- irS �('C-� .• - <br /> f <br /> e.- tn.,t <br /> 47re� clre- of-414-Ari 6 -fZ.T s Sr'f Lles-c- <br /> O< <5 re c C- 5�E= 'i qtr Via t.� — Z, > 10 <br /> Inspection Form Included: 01 �ES!gnature <br /> Comments Included: 0 -Business Rep's 'Signature Phone Number ins torPhone Number <br /> INSTRUCTIONS ON BACK C recIncolCrec#� ( �# �4rt62oa1 <br /> L�_.I--1 <br /> . White Co :CIWM Yellow Copy:Operator Pink Copy:LFA <br />