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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CIWMf181(omla Survey Form - Page 1 1 9 - 1 01 3 0 2 5 <br /> CIWMB 181(New 84104) y <br /> Califomle Integrated Waste Management Board J <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection O Inspection Type (Fill one) <br /> Site Suffix: I I 4)Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SO-it jQ 00."& Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> TA�zr <br /> Physical Address 3 1 — / O / le <br /> h,�c h/ase— <br /> Inspection Date o lO OYre," C ?AY v/ti41— Time In Time <br /> Out <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Pili all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(W ole/PTE) r O <br /> ®Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®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 /> 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 Q 114 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 * 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 Q Other: § ,�`� ..�/ 1_ ' 77 <br /> Comments Rol+&[ iq_s c di e. 1 f'1R- f' j l v W 1 �1s 'h.ri'R¢, /Y�I.�S <br /> ritrincn e T <br /> 7V f, YrIfjC4 <br /> GL e `S fit r '��c I Y� 1�4 a' <br /> Fur s�- t d r J V6 +o <br /> Inspection Form Included: I„ <br /> Comments Included: L•( <br /> _ Busines Rep's Signa u Pone Number Ins i Sin re Phone Number <br /> INSTRUCTIONS ON BACK E X A M P L 1 2 3 62081 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0708104.0086 <br />