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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 18 - 1 01 3 4 3 7 <br /> CIWMB 181(New 06/ <br /> California Integralad Wavle Managego <br /> ment Board <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- D (� /� - O Inspection Type (Fill one) <br /> Site Suffix: ' I `� *Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sm 70 T'Z'I C N Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name !v� Inspected By Inspector <br /> gess h 1 ire S P� '39 <br /> Physical Address <br /> 035 /kms St <br /> �Sca.QO n (� 9 53a U Inspection Date o � <br /> Time In '' Time Out <br /> Business Rep Title o II <br /> � '-'I L! 0 AM 0 AM <br /> BPM O � D � 0 PM <br /> `f --- Operational Status Tire Type Business Rale Storage Type <br /> ' f (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Q <br /> Tire Count(Whole/PTE) TJ <br /> a Active �Passenger d Generator `Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � Q Hauler ®Indoor <br /> O Q Inactive (9 Truck Longitude - Q End-Use Q Container <br /> Q Planned ®OTR <br /> Business Type (Fill all that appy) <br /> ®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 I'I <br /> ,,9 I <br /> Q O 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 l <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 1 Q 1 Other. § <br /> Comments 'Pispp l�ilAle vks <br /> r S -b -u i evied -TIYes to/eo( or <br /> back d * Feadlard jo wes-f all Qo v' io/cam' ns <br /> Inspection Form Included:Q e <br /> Comments Included: ��3 �` <br /> Q 6 <br /> sins kep's Sign re Photo Number. In ec is S store. Phone Number <br /> INSTRUCTIONS ON BACK jlEjXjAj1MjPrLjEj 111213] 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0609004.0003 <br />