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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Slate of Ca lifornla <br /> CIWMB 181(New 04104) Survey Form Page 1 1 3 1 01 3 51 5 <br /> California Integrated Waste Management Board <br /> Part A-Survey - _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) — - <br /> Site Suffix: r ,tom <br /> �-/ -7 7 0 Routine e Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��' 1 � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name --- <br /> r— Inspected By Inspector <br /> d. > <br /> Physical�dress <br /> 7-1 <br /> Inspection Date / _7 <br /> Gi{1 Time In Time Out l' <br /> Business Rep Title O AM O AM <br /> O PM O PM j <br /> Operational Status Tire T — <br /> pe Type Business Role .Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> 1 t ®Active ®Passenger 0 Generator Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned i 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 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ®Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part S-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility Axl P li` yT°t <br /> I <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <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§18459.3-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 <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities z•' �" ` <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § /� 1 n /► (� <br /> Comments - <br /> Gs eA ,6, ,ec X �� � 3— l —a(o e J c-s d <br /> s <br /> Inspection Form Included:0 <br /> Comments Included:0 b0 7i <br /> Business Rep's Signature .Phone Number => . .Ins for s Signature Phone Number. <br /> INSTRUCTIONS ON BACK ® X Aft P ). E Ifl2l 62081 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> t��15104.L1��5 <br />