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■ =o Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of <br /> CIWMB <br /> Survey Form - Page 1 i 4 - 1 0 1 3 4 9 9 <br /> CIWMB 181(New 04104) <br /> Cellfomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: j ,3 j 7 0 / ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier; D-zFtr-f rt Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address /� 3 9 / / SeGgao/��/`��✓A� <br /> S/C) /✓Ue <br /> Inspection Date co 6 / 09 / Q <br /> Time In Time Out <br /> BuS <br /> ssoRep Title[// Q ®AM / AM <br /> GA ��0 PM / 37 0 PM <br /> — — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r ' (Fillone 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 (Fill all that apply) - <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government p 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 •Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Y <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 /> a. fa <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB x ; <br /> r 2 <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 <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 r <br /> Q Lo Other: § .`_ <br /> Comments �aGr „/„e, _/ or y�p/< D`7i''�j 1p" <br /> 3 <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK :.,� Al p L 0 112 62081 <br /> ■ � ® ■ <br /> White Copy:CIWMB Yellow Copy,Operator Pink Copy LEA <br /> 0618604.0094 <br />