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1 <br /> ■ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of CalNornla Survey Form - Page 1 1 9 1 0 1 3 495 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- U _ Inspection Type (Fill one) <br /> Site Suffix: / / J 7 7 / ®Routine Q Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _<ZU4 VQCZC- O CHP Q CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name O _ - <br /> 7 Inspected By Inspector <br /> Physical Address 9 - S r yi/„vA 11 <br /> Inspection Date /' 7 <br /> .1 7Lp o� Time In O Time Out <br /> Business Rep=— - Title DG� S ®AM i AM <br /> DOp <br /> O PM QPM <br /> . eOR 164Q X.-4 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 ' 0 Active O Passenger ®Generator O Outdoor <br /> GPS <br /> Latitude O Q Closed Q Altered �/ <br /> O Q Inactive � 0 Truck O Hauler O Indoor s` <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder •Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires f <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 Q 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 /> Q 1 0 Other: § <br /> Comments /%✓e! - <br /> rte , <br /> "t I-e- a t-s 1;)ec ��r <br /> Inspection FormIncluded:Q a0� d <br /> Comments Included:Q -jBne Rep's ure_ Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK JPJLJEJ1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> 0618604.0021 <br />