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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State MB California Survey Form - Page 1 1 9 - 1 0 0 6 4 4 1 <br /> - CIWMB 181(New Oat1M) <br /> califomia Integrated Waste Management Board <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> —. - Business Pr�1e - --- - Inspection not-its.: - - <br /> ' TPID- inspection Type (Fill one) <br /> Site Suffix: O O �; ` ' j l„I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP O'CIWMB 0 Complaint :0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> I <br /> Ph ical ddress --- <br /> Inspection Date D 7 <br /> ” Time In Time Out _ <br /> Business Rep Title p ;O AMO AM <br /> Operational Status Tire Type PM <br /> O Business Rol 1 I O PM <br /> P ype a Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®'Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed. 0 Altered <br /> GPS Latitude •Hauler 0 Indoor <br /> O 0 Inactive 10 Truck <br /> Longitude _ 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Den'ved Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station •Hauler 0 Agriculture 0 Shredder ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility y;a <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. v <br /> 0 0 PRC§42956-Registration/Decal In Vehicle 'tl � <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB , <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§184593-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2.Manifest System Requirements for Registered Waste Tire Haulers t <br /> 0 0 14 CCR§18461--Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators S <br /> 0 O <br /> 4 <br /> Other. § <br /> Comments-r I���5—Y`22 <br /> ,� wa�C��O��e.lnrrlt. otie.e.w.tn._ .v tv`n�►.w¢u� -- - - <br /> AY} <br /> Inspection Form Included <br /> Comments Included: <br /> usines p's.Signature Phone Number Itss e i n R Phone Number <br /> INSTRUCTIONS ON BACKtt ( E 1 62081 <br /> . -s ._. ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br /> 0525804.0168 <br />