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�i Waste Tire Survey & Inspection Report Inspection Report NumberState . <br />ClWMB I California Survey Form - Page 1 1 3 -1 0 1 3 3 9 0 <br />CIWM81 (Naw 04104)California Integrated Waste Management Board <br />Part A - Survey BLUE UK BLACK INK YEN <br />IBusin Psae orI fl elel Inspection Details <br />TPID - Inspection Type (Fill one) <br />Site Suffix: 0 t . % & Routine 0 Re -inspection 0 Referral 0 Observation <br />Local I If Referral, choose referral type (Fill one) <br />Identiflert 5L 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />- <br />Buslrms or Facility Name <br />Inspected By Inspector <br />Ph ical Address 13 9 f' �% / �n-�'/•�w��(aS <br />Inspection Date 0 3 <br />lid vim')5 <br />Time In Time Out <br />Business Rep Title 0 AM O AM <br />QPM QPM <br />�"l— L i "Rt•w� Qt��-er <br />k / <br />`7 Operatbnal Status Tire Type Business Role Storage Type <br />Tire Count (WholelPTE)0 (Fill one only) (Fill an that apply) (Fill all that apply) (Fill all that apply) <br />r f Z <br />• Active • Passenger 0 Generator 0 Outdoor <br />D 0 Closed 0 Altered <br />GPS Latitude 0 Hauler 0Indoor <br />0 0 Inactive 0 Truck <br />Longitude - 0 Planned 0 OTR End -Use Container <br />- <br />Business Type (Fill all that apply) <br />_ <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dlsmantler 0 Tire Derived Fuel <br />0 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 B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <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 <br />0 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />1010 1 Other. § <br />Comments <br />T�► & q7� G 'f I'-' <br />a'_ �_ rej 44- g r�-�- c,st -t r <br />_:V:' <br />Inspection Form Included: 0 <br />— <br />Comments Included: 0 <br />Business Rap's Signature Phone Number IDdre.toes Si nature Phone Number <br />INSTRUCTIONS ON BACK E x A M P L E i2 9 62081 <br />■ White Copy CIWMB Yellow Copy: Operator Pink Copy: LEA ® ■ <br />0609004.0001 <br />