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• <br />=s Waste Tire Survey & Inspection Report Inspection Report Number <br />StateofCalifornia Survey Form - Page 1 i 2-- 10 13 3 3 2 <br />CIWMB 181 (New <br />California Integrated Waste Management Board <br />nage <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Detells <br />TPID - �7 > Inspection Type (Fill one) <br />Site Suffix: I 3 9 2 / r ® Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: 1„� .� �y fly 0 CHP . 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />J <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Address � f <br />111of N <br />Inspection Date <br />9sn <br />,t <br />Time In Time Out <br />Business Rep Title/ / 0 AM 0 AM <br />QPM QPM <br />Operational Status' Tire Type Business Rale Storage Type - <br />Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />30 <br />0 Active 0 Passenger • Generator 0 Outdoor <br />0 Closed 0 Altered <br />GPS Latitude 0 Hauler 0 Indoor <br />0 0 Inactive & Truck <br />Longitude — 0 Planned 0 OTR 0 End -Use 0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair • 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 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility s �� <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tireso <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registratlon/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 ) 4 <br />0 0 14 CCR § 18462 -Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 0 Other: § <br />Comments <br />axrr �F` L454 �s LJr 15c.,l <br />/ p <br />&4J--6 L�a9 ►� i)tr+ S ,Psctle5 4�.e ••/t es Imo, <br />it D <br />f f J`iIT�20oS-o17'rc <br />Inspection Form Included.�^ <br />o <br />Comments Included: <br />Busl ep's Signature Phone Number Ins or's Signature Phone Number <br />INSTRUCTIONS ON BACK [, 9,q`r,,,l E A �Ij, P 1 62081 <br />K <br />Yellow Copy: Operator LEA ® ■ <br />■ <br />- White Copy: CIWMB Pink Copy. <br />0605204.0527 <br />