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ii, Waste Tire & Inspection Repo ection Report Number <br /> ka <br /> State B California SU a Form Page 1 1141316 <br /> CIWMB 181(New nage V <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: ` © ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �el� 1 �Uw l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> (fin► �� �1 ert-f��s tea. ,` C `� <br /> Physical Address — I V l ,t c{✓�CJS./ I <br /> t q5L Inspection Date / Cj <br /> Time In Time Out l <br /> Business Rep i I 1 Title <br /> ,� � O AM ` Q AM <br /> )e F F Gr t L e� Gvl'�G� H& 5 o PM V ' C2 l ® PM <br /> Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ' /�' ® Active ® Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O ', Q Inactive ® Truck � <br /> Longitude — i Q Planned ® OTR Q 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 t/Ibyy/�J 7 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility T " <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q 1 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 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> iygf� <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 Q Other: § <br /> Comments <br /> -- *e' FD111Xr l rl2 - GJr_i 5 Y?c k - <br /> Cy- 47-LO43 <br /> Inspection Form Included: QI <br /> Comments Included: Q — G — auk � ''G 16�_ �7 <br /> ess Rep's Si n ture Phone Number In is ig iature Phone Number <br /> [ s2os1 <br /> INSTRUCTIONS0 BACK reE XA -1E1 1112131( <br /> White Cop :C! B Yellow Copy:Operator Pink Copy:LEA. � . <br />