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=E , Waste Tire Su*ey & Inspection Reporo Inspection Report Number <br />Stale ofCalifornia <br />Survey Form Page 1 1 2 -10 2 5 6 2 5 <br />CIWMB 181 (Naw 04f04j ^ w <br />Californla Integrated Waste Management Board <br />Part A - Survey —BLUE OR BLACK INK PEN <br />ess Profile <br />_ <br />j BusinI Inspection Details <br />TPID -Inspection Type (Fill one) <br />Site Suffix: �— 3 g ? 2 �% i • Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier:�7r 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name I j Inspected By Inspector <br />Physical Address <br />6 L rd �..� �, -a� 4 - <br />Business Rep Title <br />k- <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude — <br />Inspection Date I <br />7 l <br />Q S <br />Time In <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Time Out <br />Compfiiagr b@Iltdlltne <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />O AM <br />Q AM <br />• <br />Q PM <br />0 ' o ! 14 CCR § 18459.1 (a) (b) (c) -Tire Program 1D Number from CIWMB <br />O PM <br />Operational Status! <br />Tire Type <br />Business Role <br />Storage Type 1 <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />• Active <br />• Passenger <br />0 Generator <br />® Outdoor <br />o Closed <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 Altered <br />14 CCR § 18462 -Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 oy <br />0 0 Other: § <br />0 Hauler <br />0 Indoor <br />0 inactive <br />0 Truck <br />0 Planned <br />0 OTR <br />0 End -Use <br />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 Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler Q Agriculture 0 Shredder • Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility [gNFF0R0RN NT STIT j; <br />'Vr 41 : HAUL-ING AND MANIFEST REQUIREMENTS <br />o NotiC 19f Vi471At1ot1 <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 />Compfiiagr b@Iltdlltne <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Oita <br />0 ' o ! 14 CCR § 18459.1 (a) (b) (c) -Tire Program 1D Number from CIWMB <br />, <br />0 0 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />(R41qu7it9s`Lh1> A?4? <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 />R6fp[pd1i+'`� <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />14 CCR § 18462 -Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 oy <br />0 0 Other: § <br />- <br />CommentstQ.� +14,:�1. �i uecx <br />r,4� X4-, m d4- <br />ction Form Included: U'nSlgn. <br />qO� <br />Comments Included: 0A7� / Bus s e�Ler In s Signature Phone Number <br />62081 <br />INSTRUC 10 ON BACKncorrect. i( x a M PI 3 <br />—nor <br />KB White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />