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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 101 3 393 <br /> CIWMB 181(New 04!04) r <br /> CalNornia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Buslness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t `3 Z 6 9 a Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> G�h -Z���` �.�� rir� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ��==l�ff Inspected By Inspector <br /> Physical Address <br /> Z,— <br /> Z/ �wn1., 7 Inspection Date 03 d O <br /> 10Z Time In Time Out <br /> Buslness Rep Title Q AM Q AM <br /> ^ _ QPM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 43 (Fill one only) (Fill all that apply): (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger O Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 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 ®Other W_ 5: <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> „ I <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires = �, <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. b <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 * 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments A µ s �w <br /> t,Jti�1� P <br /> V P 41 5 Y_.__ M^ar-itcs <br /> b,%c, Ol vo i .b�_ __fL1°�lJl^c�.✓ .� <br /> V z-i t43 1 a i5 a"a5 c11�! �- <br /> Inspection FormIncluded:Q p^ <br /> Comments Included:Q +� <br /> Business Rep's Signature Phone Number I ZInssl'sSignature Phone Number <br /> INSTRUCTIONS ON BACK i4 tyi l ,' t�Pi. E 12 g 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA �� ■ <br /> 0609004.0650 <br />