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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> ri State of California <br /> CIWMB181(New 04/04) Survey Form Page 'I 1 1 1 0 1 3 6 6 1 <br /> Celifomia Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID / r j _ fl Inspection Type (Fill one) <br /> Site Suffix: is ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: s�K <br /> O __ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business ow Facility Name -- - - - <br /> Inspected By Inspector <br /> Physical Address <br /> �CB/3 qi/Yi�=E7r�t <br /> Inspection Date e g / tJ /' <br /> C y! 6 0 <br /> Time In Time Out <br /> Business Rep Title / *AM <br /> (� �aK� yU i/* sti / O - PM I 7 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 /> 41 Active Q Passenger •Generator Q Outdoor <br /> GPS Latitude D Q Closed Q Altered AI <br /> Q Hauler Q 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 0 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 f4tEhiT`$TfittlS <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Notice Of Violation 'Q,Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. ampltane Deadline <br /> Q Q •PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting RequirementsI paw <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB _ y <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 ; r <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- § a ,~ <br /> Comments '' ft <br /> 41211 _ 7 o-,y C /cute Y,?.e ,*-k <br /> Inspection Form Included: Q -0 <br /> Comments Included:Q C <br /> Business p's Signature •Phone Number Inspector's Signature. Phone Number <br /> INSTRUCTIONS ON BACK F�'f t ,* x A p 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br /> 0626304.0292 <br />