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u Waste Tire Survey & Inspection Report Inspection Report Number . <br /> Staternfa Survey Form Page 1 1 4 - 100666 $ <br /> CIWMB 181(New 04104) <br /> CaliforniaalifoIntegrateded WastCalifWaste Management Bab <br /> Dart A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Q _ Inspection Type (Fill one) <br /> Site Suffix: P Routine Re-inspection Referral <br /> OO Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: f'3" aa��'t c/, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspector <br /> Inspected By Ins <br /> s� - � 414- <br /> Physical Adtfress 3 9 - / �uR�OiHi�aV.� <br /> -- <br /> /J n� O�•.36� Inspection Date � � / � f � Q <br /> Time In Time Out <br /> Business Rep Title q ? *'M <br /> �1' (Z e-.4-,re--o �cy/f ra/al D / J 7 QPM / O v✓ 0 PM <br /> ice- Operational Status Tire Type Business Role F(Fill <br /> ge Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) l that apply) <br /> •Active Q Passenger •Generator utdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 4P Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair I*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 /> 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 /> O 1 O PRC§42951-Waste Tire Hauler Registration and Transport of Tires , + <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. r' <br /> O 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 O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years r•tP k� �5- <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 7, <br /> Q 014 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities 'w <br /> f. . <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators `? <br /> OIO _Other: § �..x,t,,..•";;�__ � -='` <br /> Comments �QGs�li}�u l�1 ! �%/2 94'11 P <br /> �/J/ ,Q Y�--``rGc✓f� - /C — ///f ,(7,Yb¢/�C+s+�ITq�t./''�*-!'4 <br /> Inspection Form Included: <br /> Comments Included: �� <br /> s Reps Signature Phone Number Inspector's Signature Phone Number IT <br /> ■ INSTRUCTIONS ON BACK IEIXIAIMIPILIEI 11122131 62081 <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> 0628404.0071 <br />