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�1 Waste Tire Survey & Inspection Report Inspection Report NumberState . <br /> cram(California Survey Form - Page 1 1 9 - 1 0 Q 6 4 Q Q <br /> Cg.to 181(New nag <br /> 4104) <br /> California Integrated Waete Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 -3 3 - 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� / If Referral,choose referral type(Fill one) <br /> Identifier: t t,` _ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Phy Ical Address <br /> r� N Fi 7L- - <br /> �� Inspection Data I n / C) 05 <br /> Time In / ` Time Out <br /> Business Rep Title O AM O AM <br /> IM ,I O Q O PM 0 2 to PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE). s O <br /> � ®Active ®Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 9 Indoor <br /> O 0 Inactive ®Truck <br /> Longitude - 0 Planned 0 OTR 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 2 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 40 Other r7��j Fl iz j" — <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility 1f <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 * 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 1 0 Other: § <br /> Comments Gt 1,4 <br /> __-- Ate_ o� r��.es.,�_-/�fC��f fS�f"�L- �, %'�5+s ►rte o✓'S_- <br /> I <br /> Inspection Form Included:0 <br /> Comments Included,0 <br /> usiness Rep's Signature Phone Number In or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I� JEJXA P I �` 1 2 � 62081 <br /> ■ While Copy:CIWMB Yellow Copy Operator Pink Copy:LEA ® . <br /> 0600604.0213 <br />