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■ i��� Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> late C.CIWMB <br /> 181(Cfnla 04! <br /> CIWMB 181 tew 04) <br /> California Integrated WasManagement Board Survey Form - Page 1 1 3 - '10 0 6 6 9 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- Inspectlon Type (Fill one) <br /> Site suffix: -7 <br /> 3 -7 - ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ryl � I^ M Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J <br /> Inspected By Inspector <br /> Physical Address 3 ` Q j G, <br /> S <br /> �//�� Inspection Date <br /> Time In Time Out <br /> Business Rep Title C O AM O AM <br /> D Z J ®PM 0 PM <br /> Operational Status The Type Business Role Storage Type <br /> The Count(Whole/PTE) S2� l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (� ®Active IS Passenger $Generator .Outdoor <br /> Latitude <br /> Q Closed Q Altered <br /> i GP$ 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 Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ®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 <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 £`3 <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB "A <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 /> 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 ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q 1 Other: § <br /> comments /1- ,4— /�.�csn, 14 CcIL / Dom. <br /> �O a..cr.It GS (/3 GiUitr'/Ati�L 4", i'C-Uft?t✓ �Zc._ <br /> �_ T7�. DIGI� Sd�ep— �4 s�.l',p �'T. ��Q '✓� i.� <br /> EMS <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Bus' ess Rep' Signature Phone Number Ins o na Phone Num er <br /> 5 10Z <br /> INSTRUCTIONS ON BACK is X R P 62081 <br /> ■ Whde Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA <br /> 0600604.0214 <br /> I <br />