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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 1 6 - 1 0 0 6 6 9 6 <br /> CIWMB 181(New 04104) <br /> California Integrated Wasle Management Board <br /> Part A.Survey__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID- Inspection Type (Fill one) <br /> SRO suffix: 6 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / - B Referral,choose referral type(Fill one) <br /> Identifier: LLii 04 Dpi jn Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business o Facility Name <br /> /� � Inspected By Inspector <br /> Physical Add ss <br /> / Inspection Date Q / 2 <br /> Time In Time Out <br /> Business Rep Title Q ®Al Zf r) AM <br /> 0 PM ( ( / ';'9 <br /> Q 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 /> r 0 Active 0 Passenger 10 Generator 0 Outdoor <br /> Latitude o Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet •Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q 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 z�f(IF�ENT 8 A_Ta w <br /> �Notice Of Violation (�� <br /> Q Q PRC§42951-/Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. int2 pad A <- <br /> Q Q PRC§42956-Registration/Decal in Vehicle , <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements 7 <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB 5�l <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 a z <br /> Q ' Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers - orsig Viµ. <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 Q Other: § <br /> Comments /ftp-- - ��� Q��( Rs.q� �o-effetrd�2yo �t/cif lzB7�e�✓� <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> us <br /> natu e Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACKIII p t7 � � 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0 6'2:-1404.61064 <br />