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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateof Catdornla <br /> CIWMS 181(Now 04/04) Survey Form Page 1 1 7 - 10 13 2 2 1 <br /> CalNomia Integrated Waste Management Board <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection alis — — — - <br /> TPID- l ' f Inspection Type (Fill one) — —She Suffix: <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> Local (7_ If Referral,choose referral type(Fill one) <br /> Identlfbr: <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — — <br /> Fr;e*iAtek ures Inspected By Inspector <br /> � _ <br /> Physical Address / O / leA41 CPQ(X <br /> Sca, (Jn /�, 95 3�O Inspection Date <br /> fuel Time In Time Out V / <br /> Business Rep Title O AM O AM <br /> 6r /t�.w T J Je A /..l h O PM — O PM <br /> lvJ 7 +�5_ �-�,�f �lv gyrational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) Q� (Fill one only) (Fill NI that apply) (Fig all that apply) (Fill all that apply) <br /> __ ©Active QPassen Passenger <br /> _ Q Generator Q Outdoor <br /> GPS Latitude 0 0 Closed O Altered <br /> Q Hauler Q Indoor <br /> Longitude t) Q Inactive Q Truck_ <br /> g Q Endllse Q Container <br /> Q Planned Q OTR <br /> Business Type (Fig all that appy) — — — <br /> Q New lire 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 40 Car Dealer Q Collection O Crumb Rubber <br /> Q 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 /> 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 /> 1010 1Other. § <br /> Comm e_ N/f s its <br /> /' <br /> %S s2od' DU Les S AQJZAW <br /> Inspection Form Included:Q. <br /> 2Q �2cr <br /> Comments Inc ud : 2 p-?35 f <br /> _ InessRep's Signature phon_e_Number Ins s Sig_ re Phone Number <br /> ■ INSTRUCTIONS N BACK E X all M P L 62081 <br /> While Copy:CIW M9 Yellow Copy.Operator Pink Copy:LEA ® ■ <br />