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Waste Tire Survey & Inspection Report Inspection Report NumberState . <br /> r' CrWM 181(NewCaflf�lSurvey Form - Page 1 1 9 - 1 0 1 3 669 <br /> CIWMB 181(New 04/04) <br /> ge <br /> California Integrated Wasto Management Board <br /> ?art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection O 6 - I Inspection Type (Fill one) <br /> Site Suffix_ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localsr: If Referral,choose referral type(Fill one) <br /> Identifier: OQ �/� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busin ss or Facility Name <br /> Inspected By Inspector <br /> Physicffl Address /rf" � Z �.,�/4Az-� <br /> ,-2 <br /> Inspection Date D <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> to <br /> PM / PM <br /> Operational Status .Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) O (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> 9 Active QPassen Passenger <br /> _ 0 Generator 0 Outdoor <br /> d <br /> Q Closed Q Altered GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that appy) <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 IV Other �/Gce ,may <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility �t <br /> "MM _ IMS u X l9?G* .tduA i,.t'•w '1�4 i Vii. .v:+int' <br /> Q Q PRC§42951 ,Waste Tire Hauler Registration and Transport of Tires ;, rY <br /> 10 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 ' z. <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 /> w....: <br /> IQ 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § _/' <br /> Comments .?r<E fh 'nsJ y t� a'a' <br /> cr� — <br /> D i'r r�e�./� u oro le _ �6 �'e� 1e9 <br /> 14, <br /> Inspection Form Included:Q <br /> Comments Included:Q6emz� _ <br /> Business Rep's Stgnat Phone Number Inspectoes Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK IEIXIAIMIPILIEE 111213 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0624904.0183 <br />