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lilt Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CrWM Kalifornia Survey Form - Page 1 1 3 1 0 1 3 2 3 4 <br /> CMIMB 181(Na.W04) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 2 Inspection Type (Fill one) <br /> Site Suffix: I y q t7 / 0 ' *Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifler: ,-Tp yL Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> � <br /> a5,7_4 <br /> D inspection Date 2 / L/ O <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> QPM QPM <br /> ,�I ar,a -Fe i -as D vjne� <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 /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fillall 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 n� " <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 /> A <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 -0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments / Z o <br /> eS s si as-fe ares i!L/•fo ed � e <br /> 4i;_H CU '% 13442 D-m eS+ S- ake ur au 9bTmaw& <br /> alis 0,0 mv (brr'ee�: �Vo �� ams nod--toQ. <br /> Inspection Form Included: �� <br /> Comments Included:0 17�-D� "V" <br /> Business Rep s tgnature Phone Number In pe ors ature Phone Number <br /> sn" 62081 <br /> ■ INSTRUCTIONS ON BACK �' X � P E'. � 2 3 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA © ■ <br />