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Waste Tire Sway & Inspection Repor' Inspection Report Number <br /> State 81(Orn{a <br /> CSurvey Form Page 1 1 4 - 0 0 8 0 2 9 <br /> CIWMBB 181(New 04104) <br /> Catifornla Integrated Waste Management Board <br /> Part A- Survey BLUE OR R_BLACK INK PEN <br /> �Buslness Profile I inspection 6,06118 <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: , 3 $ 3 ' Q Routine ® Re-inspection Q Referral Q Observation <br /> Local p If Referral,choose referral type(Fill one) <br /> Identifier: ra•�^,a �r��/1.�� 1�+ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> PhysldaI Address <br /> ^ 5Z Inspection Date C9 1 D 1 �j `� <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <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 al!that apply) <br /> U Q Active ® Passenger ®Generator (0 Outdoor <br /> D 1 Q Closed ! Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> o Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> (J) New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 CNRO � <br /> NAGItINO ANpMA1IFE8T-REQUIREMENTa �} Not)ta�t:9fflttf} <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q ; Q PRC§42956-Reg istrati onl 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 / r <br /> Q O 14 CCR 18459.2.1 -Submittal of Manifest Forms and Tire Tri Logs within 90 days / '� ' fr <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use FacilitiesO <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r i i /" <br /> Other: § <br /> Comments '�Lx-\,5�f'�'+� W`>\c' �G `v <br /> C q ,4 tiv w M$�x_ -^t Ot 1n t <br /> 2 b� -3334gZi <br /> Inspection Form Included: <br /> Comments Included: ® � (��✓ 61�Y It -- <br /> usiness Reps Ignature Phone Number Ins ctor'a S gna ure Phone Number <br /> t = , - 62081 <br /> INSTRUCTIONS ON BACK l �.� a� � , E'' +�;Nt P L E f <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />