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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of gratedCalifornia Survey Form - Page 1 1 4 - 1 0 1 3 6 6 4 <br /> CIWMB 181(New 04104) <br /> Callfornle Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile/ Inspection Details <br /> TPID- ! 3 3 6 Inspection Type (Fill one) <br /> Site Suffix: 7 0 Routine O Re-inspection O Referral Q Observation <br /> Local ^ — If Referral,choose referral type(Fill one) <br /> �– <br /> Identifier: v\ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name – <br /> � � �Q � � ���J Inspected By Inspector <br /> I o fie, <br /> Physical Address � LIB.@BTX/y�` ✓A <br /> Inspection Date / 67 <br /> Time In Time Out <br /> Business Rep Title l 0 AM nr� i AM <br /> / O PM J / v O PM <br /> -- Operational Status I Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (FIR all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator 0 Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair O Trucking Fleet Q Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station 0 Hauler 0 Agriculture Q Shredder I*Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility Y <br /> A HAtJtING { NIP Ts <br /> O O PRC§42951 Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation QEXtensim' ; <br /> 42953-Contracts with Registered Waste Tire Haulers. n- <br /> ' � PRC§ C9 Camptiaraoe Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle J E <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date j <br /> OO 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB El <br /> O Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days ( ftfOtF�r <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years Y' � <br /> x <br /> . Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q ftefarrad tc�twmg ]Erafbt6entent <br /> OKas a <br /> 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilitiesv� <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 41r<" <br /> L t CCtT#tia3tcee5 1tTa1' <br /> 7.7 <br /> O Other: § ss sx>as .ez <br /> Comments Of td –' <br /> Inspection Form Included:0 <br /> Comments Included:0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK E;XC A SIA P L E 1 , 3 62081 <br /> White Copy CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0634704,0272 <br />