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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181New Survey Form - Pgge 1 1 4 - 1 01 3 3 01 <br /> GlHomla Integrated Wasste Management 8—d <br /> Part A-Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspe n Deta(s <br /> TPID- Inspect:.X ne) <br /> Site Suffix: c p / - <U <br /> / / 3 C7 � � r 0 Routine O`We-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: l �y �f, Q CHP 0 CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name—rte <br /> Inspected By Inspector <br /> Physics ddress <br /> Inspection Date / J Q <br /> Time In !/ Time Out <br /> Business Rep Title / O AM0 AM <br /> ®PM � Z• 1 S 0 P <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) C O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J ®Active Q Passenger s Generator 0 Outdoor <br /> - O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned OTR Q End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet ( Government 0 Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body 0 Car Dealer Q Collection Q Crumb Rubber ^ytr�E <br /> Q Service Station 0 Hauler Agriculture Q Shredder 0 Other j 1�` 1C, E t p_.— <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 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 0 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 /> 00 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 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 0 Other. § <br /> Comments \W 7it <br /> t,,✓a5 �i���. <br /> -ril.�$ �nan[rK j- pj&wh,w1j 56 u,-,171L <br /> 77-3 <br /> Inspection Form Included:Q C <br /> Comments Included:Q - �` <br /> askmR Slgrmturs Phone Number s Signature Phone Number <br /> INSTRUCTIONS ON BACK IIEZIMIPILIE1 111213162081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> FjG.0t 104,r_+1G5 <br />