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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State California Survey Form - Page 1 1 2 . 1 0 1 3 3 4 9 <br /> t.IWMB 181(New 04/04) <br /> California 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: I Z 2 3 *Routine Q Re-inspection Q Referral Q Observation <br /> i <br /> Local <br /> r( � 1 If Referral,choose referral type(Fill one) <br /> Identifier: �F Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector1,9 <br /> � <br /> Physical Address1033 <br /> Q , <br /> 4 <br /> Inspection Date O / g <br /> ��o fv_ GA q sZo 7 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM Q PM <br /> operational.Status Tire Type Business Role Storage Type <br /> [Tire <br /> Count(Whole/PTE) c (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / J fj Active ®Passenger 0 Generator 0o <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler ®Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that appy) <br /> •New Tare 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 /> 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 <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 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 <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 '"f"r r���/¢y �5 y 3O t5� -,fit�,e�s wG•1 c.�- f...C.ti. kP <br /> �TJt,.�- Cf.�S�.trc V�nJ��S.. / o.�r.� I i r,� LJPJ3�" 1G-5 6✓A,r� <br /> ���-�?yroxr„•.�.-(r.�� ?� -fi.�s J e.k.,. 1 •3-�f cla,.s _ h�l/��.1.r{�y.r�-� <br /> a vtP [his rr7fG� '�W i-eStll�N.. !fin fC.�t.- Truett I j f D T 1 <br /> Inspectlon Form Included:Q <br /> Comments Included: <br /> Busintua R 's Signatwe Phone Number In actor's Signature . Phone Number <br /> INSTRUCTIONS ON BACK 1Efx1AjhkjP1L1E1 11 2 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />