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tee <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State California Survey Form - Page 1 I - 1 0 1 0 1 3 5 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK_INK PEN <br /> Business Profile Inspection Details <br /> TPID- j O - D Inspection Type (Fill one) <br /> Suffix:Sux: O` lfl 7 Q�7Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Buslnyys or Facility Name Inspected By Inspector <br /> Physical A ess O fp6r N' �,vy� <br /> S"Af K-011 <br /> Inspection Date � "g- <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM O PM <br /> - -— Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ®Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and Emend-Use Facilityk <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. 5 <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 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers a� - <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 Fac r ttew //wwr oeckff <br /> iH79$`f(v-Oi? <br /> �Ilnrp�ecti,n Form Included:Q� <br /> Comments Included:Q Anp �`-Business Rep's Signature Phone Number ctora Ignature Phone Number <br /> INSTRUCTIONS ON BACKfX I 141 IMI F I 62081 <br /> ■ 0716504.0041 White Copy.CIWMB Yellow Copy Operator Pink Copy.LEA © ■ <br />