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SI <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> t State of Callfomla <br /> CNVMB 181(NewSurvey Form - Page 1 1 9 - 1 0 1 0 6 2 3 <br /> California Integrated Waste Management soartl <br /> Part A-Survey __ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / 3 - 0 Inspection Type (Fill one) - — <br /> Site Suffix: Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local (n� // if Referral,choose referral type(Fill one) <br /> Identifier: J k,/& 7v <br /> �' �',�.-'� - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> (Physical Address 3 Y / Q / r� �,�,��D�✓J� <br /> Inspection Date 0 .8 <br /> $ / U 3 / 0 7 <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> 0 PM 0 PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count.(Whole/PTE) (FII(one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ° 0 Active 0 Passenger 9 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government QRetreader Q Dismantler .QTire 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 Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires � z z <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. "fes . <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> r <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> U <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 <br /> t <br /> Q Q 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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators = <br /> a z <br /> Q Q Other: § t� <br /> Comments i_ � ?[; -d 10,8ggdl - <br /> F)D Z) �_/1 yr3 S 6 9. <br /> Inspection Form Included:Q <br /> Comments Included:Q �u033 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACKEIx AIS P I E ! 2 62081 <br /> White Copy.CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> 07242014.0384 <br />