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=<<, Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CrWM 181(CalifOrnla Survey Form - Page 1 1 3-- 1 0 1 3 4 9 $ <br /> CIWMa 181(New 04104) <br /> Caltfomia Integrated Waste Management Board <br /> Part A•Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - I✓ Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S �QA h Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> �--. Inspected By Inspector <br /> Physical Address <br /> I'3l D �licc��a-•i --�� <br /> ZV Inspection Date <br /> Time In Time Out <br /> Business Rep Title 9 AM D Q /O 0 AM <br /> QPM / — V QPM <br /> Operational Status Tire Type. Business Role Storage Type <br /> Tire Count(W hole/PTE) /y( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> > > ' 0 Active Q Passenger 0 Generator Q Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor ` <br /> O Q Inactive +♦Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of TiresrL <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. ,�r <br /> 0 Q PRC§42956-Registration/Decal in Vehicle ' <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days n <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities rr�. <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 10 1 Other: § 1 <br /> Comments Qi./_. dpi WA .re& 0r J)&r- �;i`� <br /> arias-,L /`G,rB�e r-/tfQr � 9' <br /> _ .�� <br /> Inspection Form Included:0 ' <br /> Comments Included:Q u�� IZ1o'f,./ /r'slt3n0 <br /> Business Rep s Sign a Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK 't X A AA P i, ; 111213162081 <br /> ■ White Copy:CIWMB ` Yellow Copy:Opp erator Pink Copy:LEA ■ <br /> 0618604.0096 <br />