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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rll fiIWMB181tate of IN— Survey Form - Page 1 1 1 - 1 0 1 0 8 2 4 <br /> CIWMB 181(New 04!041 <br /> California 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 /> ffi <br /> Site Sux: / •Routine Q Re-inspection Q Referral Q Observation <br /> Local /> If Referral,choose referral type(Fill one) <br /> Identifier: r�L (��Xc�c a �� (fJ�« Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — — <br /> �� Inspected BY Inspe <br /> Physical Address <br /> Inspection Date O g / � z/, / O <br /> J•�/+•�� Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> pfd coo,24 - - <br /> 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 /> f ' 7 ®Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned •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 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 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 9`x Y •' • �" ='°`'''' <br /> p Y <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires 4 s x <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. 3. <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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers e Y <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 ,g Qsr� C Rli?y0 � <+t� pa�: <br /> B+r . <br /> Inspection Form Included:Q3 <br /> Comments Included:Q --- - — — �i <br /> Business Rep's SI 'ature ho 'Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK — � q y .~ �EzX �i/ili P'L 1 : � 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator s Pink Copy:LEA © ■ <br /> 11"7175114.A149 <br />