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=t=, Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StateB181(Nmle Survey Form - Page 1 1 8- 1 0 3 fi 7 6 <br /> CIWMB 181(New nage Y <br /> Califomle Integrated Waste Management Board <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- ? ^0 inspection Type (Fill one) <br /> Site Suffix: J g ,3 6 � Q <br /> t♦Routine Q Re-inspection 0 Referral Q Observation <br /> Lel (� If Referral,choose referral type(Fill one) <br /> Identifier: GLft Qf�C l.I O CHP O CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name •` <br /> J� �- ' � Inspected By Inspector <br /> Physical Address 3 — J Q / U6 404-44 <br /> S. <br /> Inspection Date <br /> (�r / Time In Time Out <br /> Business Rep // /� Title 9 J AM <br /> /✓Y�-"tt- F�',7 �Ht�[ hv�iriDh „� I O PM ! PM <br /> oGr Operational Status I Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t t <br /> / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active O Passenger 0 Generator ®Outdoor <br /> d <br /> 0 Closed O Altered GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned ®OTR O End-Use Q Container <br /> Business Type (Fill all that apply) �- <br /> Q New Tire Dealer Q Auto Repair p Trucking Fleet Q Government Q Retreader O Dismantler 0-Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture 0 Shredder 0 Other t�KI'fltt� vs. <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMBl'ii�l <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers - <br /> 0 O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators _ <br /> 010 Other: § <br /> Comments � y�'+.lf3e."pS�✓1 �..I �YQy �.� 9��.c �,"'f�"�pT�'i��� u/`ZJ Lc.vy�P�' <br /> le <br /> , _ �Wgnaturo <br /> Inspection Form Included:OComments Included:QBusiness Rep's Phone Number Inspector's Signature Phone Number <br /> . INSTRUCTIONS ON BACK I EWAIMI P IL I EE 1112131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 9626304.0200 <br /> I _ <br />