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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State (California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 4 - 1 0 1 3 4 09 <br /> CIWMB <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business.Profile Inspection Details <br /> l .TPID- I 0 Inspection Type (Fill one) <br /> Site suffix: i O p( •Routine Q Re-inspection Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> PAddre� s`1.�e 3 <br /> Physical Addres� \ 1 <br /> 8 5� ����,�✓✓✓✓✓✓ W. SCh41k!t--e� fit. - <br /> -Frac� CA n 5 F? Inspection Date l 0 0 <br /> 1 `� Time In Time Out <br /> Business Rep Title0 AM '] �^ Q AM <br /> o S ovin ' I] PM pC ✓ O ®PM <br /> - - Operational Status .Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE). (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> �►PS Latitude Q Hauler i Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply). <br /> •New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader -0-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 Q Other <br /> I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facilityt <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q 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 <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q1 Other: § !Ill �� �J <br /> Comments - q'fA `)a4D�2 O <br /> r *-jkck JieeS VVti2V'S . M� -* _i9 3 ll,/�"ed <br /> -11 a5 on sh <br /> are <br /> -N _ wash eL7I(/y�V!7)4p 'c Pt <br /> Inspection Form Included:Q . ggq <br /> Q ��� 5ignt��30 <br /> Comments ncluded: Business Re s Signature Phone-Number aure <br /> Phone Number- <br /> INSTRUCTIONS ON BACK I I EIXIAIMIPILIEI111213 62081 <br /> ■ - White Copy:CIWMB Yellow Copy:Operator .. Pink Copy:LEA ® ■ <br /> 0600604.0103 <br />