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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State 'fCalifornia Survey Form - Page 1 t 6 Q 2 5 7 Q 3 <br /> CIWMB 181(New 04104) ■ <br /> Callfomla Integrated Waste Management Board <br /> Part A. Sury� BLUE OR BLACK INK PEN <br /> -- - <br /> B <br /> usiness Profile <br /> _I Inspection Details <br /> D- � � � Inspection Type (Fill one) <br /> Site Suffix: 7 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Slctp' V rolw��l�[�/ �iT� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> 1 <br /> Physical Address <br /> 1 ?.p is S ./ ka4l, <br /> CA 755--37 Inspection Date z J O $ n 5 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0P 0P <br /> t Operational Status The Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 1 D i <br /> 0 Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 /> Q 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 1 <br /> ,, s <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 ' O 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 /> 14 CCR§ 16459.2.1 -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 /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers L <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities >� - <br /> 0 <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § +. <br /> Comments *)5C, o1�OW°Iv �/�' j � edCt <br /> Inspection Form Included: Q i <br /> Comments Included:Q � — - - �-3 <br /> 0 <br /> Busi ess Rep s Signa a Phone Number I at►+ Phone Number <br /> ;� �' ,'��% 'WE""T"I � 62081 <br /> INSTRUCTIONS ON BACK _, >; M P � ����2 3 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />