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U. <br />Waste Tire Su016y & Inspection Report inspection Report Number, <br />State of California j/�� j/�� <br />ClwMB181(Now 04/04) Survey Form - Page 1 ! 8 -1 4 2 5 6 5 5 <br />California Integrated Waste Management Board <br />Part A - Survey BLUE_ OR R BLACK INK PEN <br />�Buslness Profile I Inspection Details <br />TPID - + _ ! ; Inspection Type (Fill one) <br />Site Suffix: ! % Q I 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local r--� <br />Identifier: <br />Business or Facility Name <br />Physical Address <br />If Referral, choose referral type (Fill one) <br />O CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By <br />4S y - 1 v ( <br />Inspector <br />(tet- &cls <br />� <br />/ . �j Inspection Date © 5. / O '-T � Z�� Time In Time Out <br />r <br />Business Rep Title <br />Tire Count (Whole/PTE) I I <br />WE <br />GPS Latitude <br />U <br />Longitude - <br />O AM <br />O PM <br />Operational Status <br />Tire Type <br />(Fill one only) <br />(Fill all that apply) <br />® Active <br />0 Passenger <br />0 Closed <br />0 Altered <br />0 Inactive <br />0 Truck <br />40 Planned <br />0 OTR <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader <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 ® Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />! 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />Comments 45 <br />;5 /tc;;'+- <br />+ci, * <br />;— / v br //w <br />�q,1,tri LAS C__ [jT <br />/05- <br />Operational <br />0S <br />O AM <br />O PM <br />Business Role i Storage Type <br />(Fill all that apply) (Fill all that apply) <br />0 Generator 0 Outdoor <br />0 Hauler 0 Indoor <br />0 End -Use 0 Container <br />0 Dismantler 0 Tire Derived Fuel <br />LAS <br />titd-?�r)�f c=r` ((+Q� t�,J�,Yr� -�j+„� �I et <br />nspection Form Included: 0 �Va <br />Comments Included: 0*,- - <br />'s Signature Phone Number <br />INSTRUCTIONS ON BACK G�IIi'i. <br />White Copy: CIWMB Yellow Copy: Operator <br />Pink Copy: LEA <br />Z19ZCFyU <br />Phone Number <br />62081 <br />