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u Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CWM8 CalHomla Survey Form - Page 1 1 2 . 1 41 3 4 9 7 <br /> CIWMB 181(New 04!04) y g <br /> Califomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PE_N_ <br /> Business Profile Inspection Details <br /> TPID- / � � � � O / _ it/ / Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> / <br /> Physical Address 3 9 / 110 '48a 07-,jiA"- St <br /> ^ yO Inspection Date b / 07 / Q 6 <br /> Time In Time Out <br /> Business Rep may_ Title / c O AM U Q AM <br /> PM / / 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) %19� (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger !Generator Q Outdoor <br /> O Q Closed Q Altered AI* <br /> GPS Latitude ' Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container j <br /> Business Type (Flit all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 •Other Ae.1,,eLat�t�i.rt <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 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 Other. § <br /> Comments �^ei".lY_- �1 /t-Q t[ � Of slea'•d wat-,I fid e ✓ 0.4 <br /> far.,&-6 � a t�►�Z �vor.0 �or�c �Q.. Z-H .le', w--e. .rc:oiP M"7 <br /> Inspection Form Included:Q � ` <br /> Comments Included: <br /> usiness Rep's Signatu Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> 0618604.0023 <br />