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rtu Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> staleof B18l(Now Survey Form - Page 1 1 3 . 1 01 0 6 6 2 <br /> CIWMB 181(New 64/04) <br /> Callfomla Integrated Waste Management Board <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- o O inspection Type ( -in <br /> Site Suffix: 0Routine Re-inspection0Q Referral Q <br /> Observation <br /> Local (' If Referral,choose referral type(Fill one) <br /> Identifier: Yfle 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or acility Name Inspected By Inspector <br /> `ears 3 R - l o f e <br /> Physical A ress <br /> �rQ /��l Inspection Date 03 / a 8 / 0 <br /> Of Time In Time Out <br /> Business Rep Title/1 O AM O AM <br /> Cs 0 P 0 P <br /> — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f e 1 (0 <br /> ®Active ®Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler �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 /> ®New Tire Dealer •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 End-Use Facility <br /> Q Q PRC§42951-Waste Tire 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 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 <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: § �-/ /� y✓J <br /> Comments TY�IIs 1/4 <br /> 1-D 1) NL# was Il.��� <br /> lµ ti M G'h c_fog ►tikc 5tc -�i7 e EST ma w����'S kf' <br /> _ <br /> 2-00 2., ?1 ck-LVS W�nr�(AJnof�@ <br /> Inspection Form Included:Q <br /> Comments Included: �! <br /> s Rep's natud 1 PtMne Number Ins watullb Phone Number <br /> INSTRUCTIONS ON BACK I E X M P.L E 1 2 3 ® ■ <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0711604.0151 <br />