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■ Waste Tire Survey. & Inspection Report Inspection Report NumberState ■ <br /> CrWM t181(New Survey Form - Page 1 1 4- 1 01 3 6 4 8 <br /> CIWMB 181(New OG04) <br /> CalHomia Integrated Waste 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: 40 ,3 6 s 8 ..2 - D 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> � If Referral,choose referral type(Fill one) <br /> Identifier: CL/L ✓�{rt c.h - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Il <br /> Physical Address 44 / <br /> 11X9 4L- - <br /> ���/a Inspection Date D 7 <br /> Time In Time Out <br /> Business Rep Title *AM u//y /rye t,AM <br /> /44a" O PM (l / / O PM <br /> Operational Status The 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 D 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned _L0 OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 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 " a, <br /> i t <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires a k, <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB r' <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 0 Other: § <br /> Comments - �Z �+ ���// '1"se cr/Q4 <br /> /'e44aii 4e_ <br /> e6, <br /> Inspection FormIncluded: ����,1_pc� �/,-/�� \J��I/�K�✓C �D4- <br /> Comments Included:Q 1 C✓�+� <br /> usin s Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK a p t E[ 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator- Pink Copy:LEA ® ■ <br /> 41 r."� 1C14,414_111 <br />