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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 8lareof California <br /> CnYMB 181 Survey Form - Page 1 1 7 - 10 13 6 5 0 <br /> 181(Now OM84) <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details 1 <br /> TPID- / D 7 O O - O Inspection Type (Fill one) <br /> ffi <br /> Site Sux: / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Qlt %f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 0 <br /> Inspection Date 07 ® 6 / t(0 v/ <br /> Time In Time Out <br /> Business Rep Title J �/ �AM 9 AM <br /> / / / O PM / / O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2 -S.-.O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I r 0 Active *Passenger 0 Generator Q 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 /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> •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 <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 /> !OLOO <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § J <br /> Comments * /k,P Zlrj f Zvo-- <br /> A?"z 4wf iLa I o uAV.�f' aka A In <br /> &PW 94�y r�r�e. 07Z_s k-,'e wooe 4�s," <br /> Inspection Form Included:Q B A 41 � <br /> CommV � <br /> ssR p's <br /> Signat Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON B CK 10XIAIMIPTUE1. 11121362081 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0622104.0009 <br />