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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 1 3-- 1 0 13 18 4 <br /> California in Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r - ` Inspection Type (Fill one) <br /> Site Suffix: J I 0 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 <br /> Inspected By Inspector <br /> Physical Address 3 - Sty-13130l4v/ <br /> ,6'0 <br /> "0/ <br /> 75_Z3/ Inspection Date O 7 <br /> / / O <br /> Time In Time Out / <br /> Business Rep Title O AM Q AM <br /> ��•,� ���LAhaGIO �QK 0 PM 0 PM <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 /> r f 0 Active Q Passenger 0 Generator Q Outdoor <br /> '/ <br /> GPS Latitude D Q Closed Q Altered�� Q Hauler Q Indoor/' <br /> D Q Inactive Q Truc <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 10 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 . e <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 a ' <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 iQ 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 /> 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: § -1 MN1� 11 111 ,r ;,: `: 'M <br /> Comments <br /> Asorc A." ffl kx__�l��c >�^rzr � off, • Yee �, ► - <br /> /�-� 21 <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> (� 62081 <br /> INSTRUCTIONS ON BACK - EXAMPLE l 112 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0710204.0204 <br />