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=i=« Waste Tire Survey & Inspection Report Inspection Report Number <br /> State IWMBCalifornia Survey Form - Page 1 C 2 - 01 3 4 6 <br /> CIWMB 181(New nage <br /> 4104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile - — - Inspection Details <br /> TPID- / o O / Inspection Type (Fill one) <br /> Site Suffix: ( 3 / S 0 7 0 ( ®Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier. a- Zf C� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> o a-e .1"-ee- &07 2 /Ui9�9 Gs:9l <br /> Physical Address ✓ - ® / �u,R�c31 i iC//��vf� <br /> 3 d 0 B °&.'V <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep / Title ®AM f 1 AM <br /> O PM I / �"_ O 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 /> Active Q Passenger ®Generator Q Outdoor <br /> 0 Q Closed Q Altered v/ <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that applyy _ <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 p <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other 7i <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 701 T. N.. <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> PRC§42956-Registration/Decal in Vehicle14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O 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 a <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers �� r, <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities r <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .. i <br /> 4n <br /> O O Other: § <br /> Comments APUAuk <br /> J %/is f�enn -�"'p <br /> 'I�f I^-�jvl/Ltl/�� (C.C�Opsf /'Gfui'I•� <br /> Inspection Form Included: Syr-` 00013 <br /> Comments Included: - <br /> nes ep's Signature Phone Number Inspector's Signature ' Phone Number <br /> INSTRUCTIONS O BACK a i X A dpi P 62081 <br /> ■ While Copy:CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> 4_i615104.0441 <br />