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_ , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of Califomia 1f�'�� <br /> CIWMB 181 lNew 04/04) Survey Form - Page 1 V - 1 01 31 6 2 <br /> callfomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / - O Inspection Type (Fill one) <br /> Site Suffix: 9 / i Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: � oQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name d — <br /> /' Inspected By Inspector <br /> Physical Address <br /> .�2 7 <br /> Inspection Date � � � /' ! / <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status 'Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' _370 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f0 Active 0 Passenger •Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned OTR Q 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 n' <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 7Q 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 B` r <br /> Inspection Form Included:Qi <br /> Comments Included:Q <br /> _ Busi Ignature Phone Number_ Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK l e PL7E 1 2 3 6208 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0708104.0051 <br />