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Waste Tire SU*ey & Inspection Repor' Inspection Report Number <br /> State WMB1alifornia Survey Form Page 1 1 9 - 1 0 1482 4 <br /> C1WMB 181(New 84104) � <br /> • California Integrated Waste Management Board <br /> Part A- Sy-"e _ _ _ . _.- . _-__ BLUE O_R BLACK INK PEN <br /> Business Profile _ _ Inspection Details r� _ _ — <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: J 3 ® 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 <br /> ( Inspected By Inspector <br /> YN-A- ��� ( { <br /> Physical Address��� <br /> � o� <br /> Inspection Date o <br /> S l <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> �- — Operational Status TI a Type Business Role r Storage Type <br /> Tire Count (Whole/PTE) <br /> r (Fill, only) (F II all that apply) (Fill all that apply) (Fill all that apply) <br /> � � l� � p <br /> ® Active Passenger 8 Generator ® Outdoor <br /> 0 � Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> C Q Inactive Truck <br /> Longitude - Q Planned Q OTR j O End-Use Q Container <br /> Business Type (Fill 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 r • ' <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (a Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> O O JPRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O Q <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> � i/, /� ,✓ <br /> O ® 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB ��, ,��✓ / <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days // <br /> / <br /> Q O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> VA <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments �+,��• .,. �].s,G_] " L _�� C_ - { ,$ t7 <br /> - N _ 60 S.f a'v _ oto oin.` <br /> u--a c c La <br /> tA.2 <br /> VA4j K S�S f DU i�►�1-(� �4` L1i L L�'�-S 1 V�t� W�-�.. ��"G1i�v�. b S��'C.r: <br /> :Inspection Form Included: Q <br /> Comments included: Q - <br /> 8usine s Re SlPhone NumberIn�tar's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK / E' rah L E 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />