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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> f 71 State of California <br /> t CIWMB 181(New 04104) Survey Form - Page 1 I $ 1 0 1 3 3 $ 4 <br /> Califo is Integrated Waste Management Board <br /> Part A-Survey — BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site suffix: ` 3 �- 6 3 3 - ( ®Routine Q Reinspection O Referral Q Observation <br /> Lel If Referral,choose referral type(Fill one) <br /> Identifier: � C[�. li Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name+ L / Inspected By Inspector <br /> PhpS� _ <br /> sic Address C> 191­��5 <br /> 9 C5 j Inspection Date 0 0 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0P 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> t O ®Active ®Passenger •Generator IS Outdoor <br /> D Q Closed Q Akered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive I®Truck <br /> Longitude - Q Planned OTR . Q End-Use Q Container <br /> Business Type (Fill all that appy) - <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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility <br /> 070 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 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 b <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> "a <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days s <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years s <br /> str <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 /> CommentsaCyL/ <br /> 'f"% <br /> Inspection Form Included: D <br /> Comments Included:Q <br /> Business Rep's Si ature Phone Number pector's Si nature_ Phone Number <br /> INSTRUCTIONS ON BACK 0 X A P p 3 62081 <br /> . White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA © ■ <br /> 0609004.0004 <br />