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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181st(Now04/04) Survey Form - Page 1 1 8 1 0 1 0 8 2 9 <br /> California Integrated Waste Management Board <br /> Part A-Survey - BLUE_OR BLACK INK PEN <br /> Business Prefile _ Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: t{ ({ 00 <br /> 7 - 0 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: O4�f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name tJ Inspected By Inspector <br /> Physical Address -3 9 - / /p / <br /> S 7ro L spy/ �/ / (/ � Inspection Date 09 <br /> 3 / 7 <br /> ( Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <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 /> ' Active Passenger 0 Generator •Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 11 Auto Repair Q Trucking Fleet Q Govemment Q Retreader Q Dismantler <br /> Q The Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 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 /> Q 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 /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities . ,^ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q 1 Other: § <br /> Comments 44xe� "?id/,,, 011 9C-,:f 61 a&,e �Q�trd 4l <br /> 4ei t'./94, &iej /��j -m i�Llmd� G�/ �'�/�s L� s� <br /> Inspection Form Included:Q <br /> Comments Included:Q"'A- _ /_01 y�` �3 7 11QA+�' f� ��,� <br /> Business Rep's Signature Phone Number tnspectoesSignature _ Phone.Number <br /> ■ INSTRUCTIONS ON BACKE°xL s A p 2 62061 <br /> E 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA ■ <br /> 0724204.0386 <br />