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-Ed Inspection Report Number <br /> Waste Tire S*ey & Inspection Repor , <br /> IVVMBStatO f 81(New Survey Form Page 1 1 8 - 1 0 2 8 7 3 8 <br /> CIWMB 181(New 04104) ., <br /> California Intogratod Waste Management Board <br /> Part - Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details I <br /> TPID- G - Q Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By inspector <br /> ct <br /> Physical Ad ss <br /> S '5 0'J <br /> * Inspection Date 0 2— <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PNI <br /> Operational Status Tre Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Bill all that apply). (Fill all that apply) (Fill all that apply) <br /> Z ® Active 0 Passenger Q Generator O Outdoor <br /> Latitude 0 Q Closed b Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ — - Q Planned _ Q OTR —I 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler •Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> ";.yn/i; J4�:N :� � � -i/ /,/..;i✓// �/ / �".^"�; <br /> //w / f 'a///./•,' j<%�/, �.'J" <br /> n'Y.: .�>tFrJ .�J'�/: �'+•�: .,P$1G1!JI,��G f�i/ri'/J/J{i � /• / /- <br /> Q .O/ PRC§42951 -Waste Tire Hauler Registration and Transport of Tires J✓" iir.' J %s �� / " <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. �� <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 14 CCR§18459 -Responsible Entitles Complying with Manifesting Requirements <br /> O Q <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q O 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 /> O 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 /> O Q Other: § <br /> Comments <br /> Q�\rfi G�t.� <br /> J7•� ,Q•5 r� . _ ` teal L� v�Dcc�j �/ C Via In O C' V�HtAU r� <br /> Inspection Form Included: Q !R?� <br /> Comments Included: Q - ---- - - —g� - <br /> Basin ss Rep's Signature Phone Number_ ect _ _ _ Phone Number <br /> /�JP pvg mog, ,'gg';� .��� 62081 -- <br /> INSTRUCTIONS ON BACKnJ % "� %hit P L <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />