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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State (California <br /> Slat Survey Form - Page 1 { 3 - 10 2 5 6 5 9 <br /> ' CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-_Survey BLUE OR BLACK INK PEN <br /> 1 Business Profile inspection Details <br /> TPID- a Inspection Type (Fill one) <br /> Site Suffix: 3 q / Z 14) Routine Q Re-inspection Q Referral Q Observation <br /> LocalX17 �+ If Referral,choose referral type(Fill one) <br /> Identifier: �rir. J ����� lJl.,r-�7 14.D0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> yrs � i <br /> Physical Address ' C <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title AM Q AM <br /> 0P 0P <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 /> C7 Active ® Passenger (9 Generator ® Outdoor <br /> i <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler � indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair *Trucking Fleet Q Government Q Retreader ® 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End Use Facility �N' T_ TATU8 <br /> ,i I�AU�.INti MAI F88T IiRQUIREMON.T- <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 1CI018tG.iy. QE)ItenelOn <br /> / 9 f <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. � plagll .e <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 /> O Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days f�� S�i E NOV OC . <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 I� IttQF'CtRllt = <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § _. <br /> Comments s/�G. I� �i ---�1.Jnra.�.-��— rt�^K '71—�/�aC �lQ�.--1� a �D►�-c- <br /> __ IrY_e_& 4�11 r-e_ Lrl__-"� JYY_�5 -:�11-e— <br /> --A►-v..;�r �,,_ &,-- I-���le� Ct,.�; +-✓41' <br /> Inspection Form Included: Q <br /> Comments Included: — <br /> Business Rep's Signature Phone Number In or's Signature Phone Number <br /> INSTRUCTIONS ON BACK �GOPJYil#; xlt3$t / ` Ex �l;r'JtrFL�� � z 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br />