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Waste Tire Survey & Inspection Report Inspection Report Number <br /> r' StataofCallfornia Survey Form Page 1 1 4 01 31 1 1 <br /> CIWMB 181(New od101) <br /> California Integrated Waste Management Board <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _7 5 Z _ Q / Inspection Type (Fill one) <br /> Site Suffix: 1 ®Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name '� 7 <br /> Inspected By Inspector <br /> Physical Addr,s� _ ^\�!j Air— <br /> M4 5 <br /> Inspection Date <br /> / Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> 0 P QPM <br /> – - Operational Status Tire Type Business Role Storage Type <br /> 1 <br /> Tire Count(WholelPTE) t%' � D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O Active •Passenger ®Generator *Outdoor <br /> Latitude Q Closed O Altered <br /> GP$ 0 Hauler 0 Indoor <br /> 0 Q Inactive O Truck <br /> Longitude – O Planned Q OTR End-Use i Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet 0 Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body •Car Dealer O Collection O Crumb Rubber <br /> O 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 /> 11111 <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § <br /> Comments e/ <br /> q 0"X"'—A 01-de-1 a vee, I C+r c Q rv`14 <br /> if O r" Li <br /> Inspection Form Included:Q <br /> Comments Included:0 <br /> Business Rep's Signature "Phone Number Ins Slgnat r Phone Number <br /> INSTRUCTIONS ON BACK P .L f 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0723504.0124 <br />