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Waste Tire Survey & Inspection Report Inspection Report Number <br /> state CIWM of California Survey Form - Page 1 ( 9 - 1013339 <br /> CIWMB 181(NewW04) <br /> nags <br /> Calilomla Integrated Waste Management Board <br /> Part A-Ss BLUE OR BLACK INK PEN <br /> _Business Profile _ �Inspection Details <br /> TPID• cy / inspection Type (Fill one) <br /> Site Suffix: 3 D Z b © Q Routine ®Re-inspection Q Referral Q Observation <br /> Local f If Referral,choose referral type(Fill one) <br /> Identifier: Jt�.��y �({� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facilityy Name Inspected By / Inspector_.L� <br /> Physical Address <br /> Inspection Date <br /> G75z�s <br /> Time In Time Out <br /> Business Rep Title �19 AM O AM <br /> I / ' 51�11PM O PM <br /> Operational Status Tire Type 1 Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r t ®Active 40 Passenger •Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ®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 0 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 1 Other: § <br /> Comments <br /> �_-ci-I— q' ���. G,'lr�!� � `b r� 7�� �r✓ Or-- w.oy� <br /> 11ih A J7 -, ••,�.s -_ 1 t_v,r.S ar�C O,I s o crt.ri t�.e.Q i -cr.*,r--s a. <br /> IJp _�JJbla�iaa..4 <br /> Inspection Form Included:Q � �/ <br /> Comments Included:Qfo <br /> _ B Iness Rep's Si In ature Phone Number s Slgn Phone Number <br /> INSTRUCTIONS ON BACK FErXRhk1P1L1E1 11 2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0603104.0170 <br />