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■ <br /> �i Waite Tire Su Aly & Inspection Report Inspection Report Number <br /> 4 <br /> State of California <br /> w CIWMB181(New 04/04) Survey Form - Page 1 i i - i 0 10 5 4 u <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- + f,.t Inspection Type (Fill one) <br /> Site Suffix: ! I I J _ I - Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ry If Referral,choose referral type(Fill one) <br /> Identifier: 1(+ (�. <br /> � -� ( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I <br /> Inspected By Inspector <br /> Physical Address f(' <br /> S1 -- <br /> Street { <br /> f t l Inspection Date <br /> Cl� State Zlp Code I Time In Time Out <br /> Business Rep i Title, , 1 AM O AM I : [ <br /> LPE <br /> t ' Q PM 0 PM <br /> I hai'l') �!' —� ':e tCC r�l ( (k)YlriC ('A <br /> - Operational Status Tire Type Business Role Storage Type <br /> _ .t. �.., s (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(1�lhole/PT�) <br /> r Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude . O ® Closed Q Altered QHauler v <br /> Indoor <br /> Q Inactive Q Truck <br /> Longitude - J� <br /> T777r/­,ff <br /> Jj 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 Q RetrE - <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crun <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Othe re <br /> Part B - Inspection of Waste Tire �eLler, Generator, Hauler and End-Use <br /> V A l HAULING AND MV t6 IFEST REQUIREMENTS <br /> Q Q PRC§42951 -WasteTire 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 EntitiessComplying with Manifesting Requirements =KII�UStr l G\ S�pPI� . <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB `J <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days t s �3uS lY1R,SS rl csrv� <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years Ct,5S0 G 1 Urea �� -T F�v <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Houle <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 Gel <br /> Q Q Other: § <br /> Comments ) <br /> .,� ( Y1 l�,V C I '. ✓ t; i ;,i.t� a ; t1 -l it;_ C1i' <br /> -�'"�t�F�.�{:l.l� ft.c i !.'!�.��f�1 � �rL �iJ �=�YI c� V''�� ►�-..(i � j�,'�t,I ;.)(,fly c �` r � r��� ��- ,�t,, <br /> 0 lc 7 <br />} <br /> Inspection Form Included: Q' <br /> Comments. Included: Q - <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> . � 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ;; A V, 4' L.�� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />