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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04104) Survey Form Page 1 t 1 . 10 13 6 3 7 <br /> eallfornla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID• Inspection Type (Fill one) <br /> Site Suffix: / .j g / 3 � � I <br /> A Routine Q Re-inspection Q Referral Q Observation <br /> Local / _ If Referral,choose referral type(Fill one) <br /> Identifier: ��_ C/f7 <br /> _ 2L H Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busine or Facility Nam/e' Inspected B <br /> r� tdi-P c p Y Inspector <br /> Physical Address 3 <br /> - <br /> SInspection Date <br /> Time In Time Out <br /> Business Rep Title Q *AM ®AM <br /> ( O PM C' 9 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 /> t ' Y ®Active Q Passenger ®Generator Q Outdoor <br /> GPS Latitude O Q Closed Q Altered ,!/1 <br /> N Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude 0 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 Q Retreader Q Dismantler Qire Deri <br /> TjFuelQ Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb RubberQ 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 O PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. -> <br /> O Q PRC§42956-Registration/Decal in Vehicle »: <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements a ' <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB S r <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days z3ry <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 <br /> Q Q Other: § <br /> Comments A-a&p <br /> X-ad 4/l- "i'F y'W . xw/te <br /> WVe Y­�-/t S aor W.,, .c eke &,Vz a le � •� �+�� <br /> G-tz91-4e '&W Ae'e' k'` toe GO,& 4111* J4_ ?e 4 A 3 as <br /> Inspection FormIncluded:Q <br /> 4 <br /> 41 <br /> Comments Included:Q— �' /'� yerz Oj B <br /> Bu ass ep's SignaturePhone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK62081 <br /> While Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0E.19404.Ctt_14y <br />