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u Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State lffornia <br /> of Form - Page 1 1 7 - 1 01 3 1 2 2 <br /> CMIMB 181(New 04104)New <br /> calitomia Integrated waste Management Board <br /> PartA-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> 81te Suffix: I �.�- 3 ?J 3 - © ® Routine Q Re-inspection Q Referral Q Observation <br /> Local _� /' If Referral,choose referral type(Fill one) <br /> Identifier. -�{y LFN/) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> /�- L Inspected By Inspector <br /> �AH �r✓1q��.,0.- f liJ,.a� �Irt.�.StrT �f _.}.�-, <br /> Physical Address <br /> �+ Inspection Date Q / 7i <br /> Time In Time Out <br /> Business Rep ! f - Title Q AM Q AM <br /> Q PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> ' Q Active ®Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler S Indoor <br /> 0 is Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Typo (Fill all.that apply) <br /> Q New lire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 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 0 Other <br /> Part B Inspection of Waste Tire Dealer,Generator Hauler and End Use Facility `- ` <br /> t <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires , <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. ° t <br /> Q Q PRC§42956-Registration/Decal in Vehicle a <br /> Q Q 14 CCR§16459 -Responsible Entities Complying with Manifesting Requirements <br /> 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 Q 1 Other. § <br /> Comments ] <br /> !��, r .-!1 /r.tt{iv :.:✓,.r, S�'F-C �.-n -�.,L�u �4-S Gie-0— (2E <br /> Inspection Form Incfuded:Q <br /> Comments Included:Q! <br /> Business Rep's Signature Phone Number &.r.INSTRUCTIONS ON BACK 62081 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0 F.2,r,'1714.4_1 28 4 <br />