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« , Waste Tire Survey & Inspection Report Inspection Report NumberSlate . <br /> CCWM of California Survey Form - Page 1 I $ - 1 0 3 7 6 1 <br /> CIWMB 181,New 04/04) Y <br /> CNHomla Integrated Waate Management Boartl <br /> Part A_SU <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I O Inspection Type ( one) <br /> Site Suffix; `i30 2 © Routine 0Re-inspection O Referral O <br /> Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB O Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name U inspected By inspector <br /> Physl'cal Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep I / Title Z AM /7n1 0 AM <br /> OI .� v1 V^v y �(_„ _ `/ + S O PM O V ®PM <br /> Vv r/ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill.all that apply) <br /> ' r 0 Active 0 Passenger I,Generator 0,Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) _ <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismander 0 Tire Derived Fuel <br /> 10 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture O Shredder Other R,i d tr fu►16L�acur <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O ,:...- <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Or c, <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle : <br /> Y. <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ` <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days a„ yk <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 yearsN <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers , <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators , <br /> 0 0 Other: § <br /> Comments lhuhmI 1 A o j r has 'w <br /> 1070 Av TKr o 'n aiA ' �' P e. X110 <br /> r .-111 r <br /> Inspection <br /> Form Included: <br /> Included:O - - ` - \ <br /> g - <br /> O Bus see Rep Signature Phone Number Ins a or's S ature Phone Number <br /> sem, s q x 62081 <br /> ■ INSTRUCTIONS ON BACK �,, EX A M P:L E 111. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 0617904.0252 <br />