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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State California Survey Form - Page 1 I 0 1483 3 <br /> CIWMBB 181(New 04104) ■ <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Bualness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> Routine 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 or Facility Name `- �- - -- -- -- <br /> `4��, � � Inspected By Inspector <br /> Physikl3I Address �j 0 <br /> - <br /> Inspection Date lo, J Z / IJ 5 <br /> Time In Time Out <br /> Business Rep p 1 Title 0 AM - 0 AM <br /> 5�1�/l`GL `r(`,,,4�,v�W.c,4•�.� - -t L/\� - -- --- O PM - 0 PM <br /> V Operational StatusF(Fill <br /> e Type Business Role . Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Passenger Q Generator Q Outdoor <br /> - - - - _ — --- 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - - - Q Planned Q OTR - I Q End-Use Q Container <br /> Business Type (Fill all that apply) J <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 -f`tL, rtt,u <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® 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 y / <br /> Q O 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 �O (')�th., 5"18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q <br /> Comments <br /> ` ^'`5 5''lc'W. <br /> V _ - 1N�j__ov�•t� - <br /> 64. <br /> `� �- <br /> - L <br /> { <br /> a-e, �.° _l�l� _ �'V'�`7 'C 1��,�2s t <br /> Inspection Form Included: Q7�A' - <br /> Comments Included: Q <br /> usine ep's Signature Ph6pe Ndmber Insp tolls Signature P one Number <br /> '- — I p 62081 <br /> INSTRUCTIONS ON BACK �`;X AAMS p L t: 11? 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />