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rr¢ <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CIWM f 81(New <br /> Survey Form Page 1 1 7 1 0 1 3 1 6 3 <br /> CIWMB 181(New 04104( <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Detalls — --- <br /> TPID- �/ ^ Inspection Type (Fill one) <br /> Sitesuffil / 3 / Z 3 r ♦✓ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localf/� If Referral,choose referral type(Fill one) <br /> Identifier: d� r 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 3 <br /> a3/3 &a.� �- } <br /> (7/- <br /> Inspection Date <br /> J`74a_&� <br /> Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> O PM QPM <br /> operational Status Tire 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude <br /> O 0 Closed 0 Altered <br /> GPS 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 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 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 /> 0 0 Other: § <br /> Comments .,.,1 �P�� e.1,.,. �j�" QK �' •• ��in� <br /> Inspection Form Included:0 <br /> Comments Included:0 Business Rap's ST-gill 'Phone u ber Inspector's Signature _ Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPI f 2 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0705904.0326 <br />