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. cC=• Waste Tire Survey & Inspection Report Inspection Report Number <br /> rr StataerCa�Nonia Survey Form - Page 1 I 3 01 3 41 G <br /> 1:IWMB 181(New 1.104) <br /> Callromia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> jBusiness Profile -_ I Inspection Details <br /> TPID' 3 n 5 _ o Inspection Type (Fill one) <br /> Site sutnx: �J I ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educations{Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> vs 7 �cciu►'� �� 3 q - j 0- ! ptyt� z <br /> Physical Address <br /> -V'50 f-, <br /> Inspection Date 'Z <br /> Time In Time Out <br /> Business JR�ep Title I I D i AM ' O AM <br /> ,S 1l R� s� ,/ - O PM O ®PM <br /> ---+�— Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) d r O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 01 le Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler (r)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 ®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 <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 <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> CommentsAMAM <br /> �IoKJ ►IJ�GS Yt0 CDS:- -- (.L 105- '40n4,'; Oil.,&bf +1.i ' 0' <br /> 4) fires as �r�ced of ! `o n. M C Tnr� bri e s s a F <br /> -hirts akid r •;rte ) -flreS, lIvoic :TressAxed cover p oov - <br /> Inspection Form Included:Q - 701 <br /> z��Y�_z��s �' <br /> Comments Included:004�_ _. - - - <br /> Business ep's gnature Phone Number I ti tor's i a ure Phone Number <br /> INSTRUCTIONS ON BACK [ I il1A P :L 1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0620604.0187 <br />