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.r.. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StWMB1at of all(New Survey Form - Page 1 1 8 - 1 0 1 0 6 3 2 <br /> CIWMB 181(New 04!04) <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I - O Inspection Type (Fill one) <br /> Site Suffix: U ®Routine Q Re-Inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Sin Ic I <br /> �}— <br /> ��aQr v Q CHP Q CIWMB Q Complains Q Educational Visit Q Other <br /> Business or Facility—Name Inspected By Inspector <br /> _ / <br /> Physical Address 3 1 O <br /> .J <br /> pe'RC4 ante <br /> '� � ��� r Inspection Date / O <br /> I�J'n.L /V/tl- r Time In Time Out <br /> Business Rep llTitle `� O AM O AM <br /> JQUI fal - 1$0r OPM 0 P <br /> - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W holelPTE) O (Fill one only) .(Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> ®Active Q Passenger ®Generator S( <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®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 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 /> Rol <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires F - <br /> i <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 Entitles 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 a <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers , _ n <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 3 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other. § Y <br /> Comments (h Qy1�l S C.L1��C, f h0 [OII !aS n ; (S F <br /> W_ -tire f-l0-f wy,t a.v cel re�r_ed 5 to +. CTL 4AAA - <br /> s+c, F,,>rH,�ewl.ovowed-,_ Vii_ _ M MOA <br /> udkr o-Nc) ✓;pia ns <br /> inspection Form Included: <br /> Comments Included:Q P�+ <br /> Bit ess ep'sSignature Phone Number s ecto s nature Phone Number <br /> ■ INSTRUCTIONS O J ACK , Y �( A p I 62081 <br /> X5 .4 ® ■ <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA <br /> 0700104.0063 <br />