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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of Now <br /> Survey Form - Page 1 1 3 . 1 0 0 $ 0 0 <br /> CIWM8181 181(Naw 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK_ INK PEN <br /> Business Profile - Inspection D41talls <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: y o f Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �^ r If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> ---�- Inspected By Inspector <br /> 1 Co Ad5 E'*S. 1`�rc Sct;q- <br /> Physical dress <br /> 5 7 <br /> 376 Inspection Date <br /> Time In Time Out <br /> Business Rep Title C)AM O AM <br /> O PM 0 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 /> t r 10 Active * Passenger Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive IS Truck <br /> Longitude _ 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityNRt R M T$.T, $ . <br /> V:° A. MAULING AND-1YIANIFEST REQUIREMENTS D;N do of Y1 1+ 0 s <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> , C.ampil■rcfi q�,(�il�i< ,, ; �� <br /> 0 0 PRC§42956-Registration/Decal in Vehicle { <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements p {�El <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 1 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 '�� , ' i„ ✓, <br /> Y i, ��-�j/� �r�%✓%%,;ilii �f���.,i <br /> 0 1 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities s !� '�':�• <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Othef: § <br /> CommentsVttj/ L <br /> vr)s or- <br /> o.�-- <br /> `�nc � C-e- <br /> 31 <br /> Inspection Form Included: <br /> Comments Included: 0 - - J� - 3 76E� <br /> mess R s Signature Phone Number <br /> Phone Number <br /> INSTRUCTIONS ON BACK 106r,rec . `-trim: NJ E X ATP (~ szoal <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />