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aWaste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateof18lilornia Survey Form - Page 1 1 2 - 1 0 1 3 2 1 7 <br /> CIWMB 181(New nage <br /> California Integrated Waste Management Board <br /> Part A-Su�_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> � D / Type (Fill one) <br /> Site Suffix: le Routine <br /> Q Re-inspection Q Referral Q Observation <br /> Local { If Referral,choose referral type(Fill one) <br /> Identifier: \ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business olr�Facility <br /> -{Name Inspected By Inspector <br /> Physical <br /> ' ^fL '753 P-O Inspection Date t} /) I <br /> /l/ o <br /> Cil/.zJ- Time In 11 �- Time Out (J <br /> Business Rep Title / O AM Q AM <br /> � <br /> 644 ��VI L / O PM O PM <br /> --FF J <br /> Operational Status Tire Type Business Rola. Storage Type <br /> Tire Count(Whole/PTE) a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ®Passenger O Generator Q Outdoor <br /> Latitude <br /> O Q Closed Q Altered <br /> GP$ Q Hauler a Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned s OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 40 New Tire De er O Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 4P 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 /> —I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Faculty <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§16459 -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 /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q- Other: § <br /> Comments' AA I My 1� <br /> Vieujd <br /> I <br /> Inspection Form Included:Q - <br /> Comments Included: ` "— —I`�U--r,167"'v <br /> Business Rep's SI e. Phone Number 31n oes I ure Phone Number <br /> INSTRUCTIONS ON BACK E X IM P E 1 2 3 62081 <br /> ■ While Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0708164.0081 <br />