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Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New04104) Survey Form - Page 1 1 8 . 1 4 4 7 5 7 <br /> California Integrated Waste Management BoarA <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> IBuslneesProflle Inspection Details <br /> TPID- j Inspection Type (Fill one) <br /> Site Suffix: 1 ID S; 7— 5 Q 0 Routine 0 Re-inspection Q Referral Q Observation <br /> 1 Local /'+ If Referral,choose referral type(Fill one) <br /> Identifier: �a , ��� �� L�z7�-�v�^�'y 0 CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> � <br /> � � <br /> 'Physical Address ��s / C� � l��^1r►'�,� �jd��%tn5 <br /> Inspection Date Cj— <br /> �s�,lo� �A `1S3zv <br /> Time In Time Out <br /> I Business Rep Title O AM O AM <br /> 0 P 0 P <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 /> 0 Active Q Passenger Q Generator Q Outdoor <br /> O @P Closed O Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O <br /> Q Inactive Q Truck <br /> Longitude — O Planned Q OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility �ENFRR T <br /> V t HAtJ Nei AIN 11111A <br /> NIJESTAIIQUIREMENTS <br /> 0 I0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q NOtlStd 0-YIN4 4nlrt <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Co <br /> 0 , Q PRC§42956-Registration/Decal in Vehicle ` <br /> Q 014 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DotR <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB , <br /> 014 CCR 18459.2.1 Submittal of Manifest Forms and Tire Tri Logs within 90 days <br /> § p 9 Y <br /> Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ;­ // s. <br /> O Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers i Q �tl <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q , Q i4 CCR 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O OOther: WIN /�//�/�/,i/,�N <br /> , <br /> Comments <br /> i n <br /> ejotrlt 014x-4— o C� Wary. ��he.t: I^e K <br /> Inspection Form Included: O <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number <br /> Ins tar's ;aura Phone Number <br /> INSTRUCTIONS ON BACK �_ t1R ( �/) +� ,N4 P L �1 f 2 J 62081 <br /> � <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />