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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California Survey Form Page 1 1 2-- 1 0 3 6 3 8 <br /> CIWMB 181(New 04104) <br /> Cellfomla Integrated Waste Management Board <br /> Part A-Survey _ _ _ _ _ BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details <br /> TPID- r� -7 � - © / Inspection Type (Fill one) <br /> Site Suffix: (/ Routine <br /> _ - ® Q Re-inspection Q Referral <br /> ation <br /> _ <br /> Q ObservOLocal If Referral,choose referral type(Fill one) lVstIdentifier: Q CHP Q CIWMB Q Complaint Q Educational Visit <br /> Q <br /> ther <br /> Business or Facility Name — <br /> �Z � , amInspected By_ Inspector <br /> Physical Add <br /> 0 / D <br /> Inspection Date C" / a <br /> Time In Time Out u <br /> Business Rep / Title q ` Q AM Q AM <br /> •PM / eL— 0 PM <br /> Operational StatusTire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) n( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active QPassen Passenger <br /> 0 Generator Q Outdoor/ <br /> Closed Q Altered <br /> GPS Latitude 0 Q ClQ Hauler Q Indoor <br /> 0 O Inactive 41 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) - - <br /> p New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment 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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityMom 15-W-12 <br /> mss' <br /> 1 <br /> F � <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 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 O 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 <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 1 Q Other. § <br /> Comments rQG'.I'•�7'� G��J LT"�i e!'��- Q��'G �!/a�C I7/'t� Qlil �i PC <br /> Inspection Form Included:O <br /> Comments Included: ` =l�J. !v�c��`�f�✓/�`+ �oQ 3�' <br /> Business Rep's Signature Phone Number inspector's.Signature Phone Nutnber <br /> ■ INSTRUCTIONS ON BACK JEJXJA IM 1 2 3 62081 <br /> White Copy:CIWMB Yelbw Copy:Operator Pink Copy.LEA ® ■ <br /> 0619404.0048 <br />