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=i Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181(New 0,1104) Survey Form - Page 1 I - 1 01 0 6 3 8 <br /> California Integrated Waste Management Board <br /> Part A-Survey -�-�y BLUE OR BLACK INK PEN <br /> Business Profile 7 'g V — �r� Inspection Detalls <br /> TPID- j Inspection Type (Fill one) <br /> Site Suffix: 14 a Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Oct Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> AdT <br /> � T <br /> PhysiP Y Inspector dress — l O <br /> Inspection Date D 3 / 2 D <br /> Time In Time Out <br /> Business Rep n! Title / Q AM Q AM <br /> O 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 /> Active Passenger® ® g Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned �Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair IS Trucking Fleet Q 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 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 .; N <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle . ' ' <br /> Q Q 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements r <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Fd . . <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 •���Y"� �a� =. �•=.• � , <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 � rx <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q 1Other. <br /> CommentsRadia <br /> � 5L&QA 7fri2 *t cus &'09 o�t� 3-Y natrx lcs T <br /> S <br /> Inspection FormIncluded:Q <br /> Comments Included:Q 70L L_ ,fie v��9066 <br /> Busl etss R <br /> oB;qOhnature _Phone Number In Phone Number <br /> ■ INSTRUCTIONS ON BACK jEj.XjAjMjP[L1Ej 111213 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA <br /> X17 11r-.A4,A147 <br />