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Waste Tire Survey & Inspection ReportP port Number ■ <br /> Ins ection Re <br /> state of cautem� <br /> CIWMB 181(Now 06/04) Survey Form - Page 1 1 5 - 1 0 1 3 2 4 4 <br /> califomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details - -- - - - <br /> T�D' D 4 -3 .5 <br /> J - Inspection Type (Fill one) - - -Site Suffix: i/ l Routine <br /> Q 40 Re-inspection Q Referral Q Observation <br /> Local H Referral,choose referral type(Fill one) <br /> Iderdlfier: �Fw <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> GHInspected By Inspector <br /> Physical Address <br /> 3.33-2,n nl <br /> � Q57-0 Inspection Date© 0 -7 <br /> Time In ( Time Out <br /> Business Rep (� Title O AM OAM <br /> O PM - - O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count'(Mole/PTP (Fill one only) (Fill all that apply) (Fill all that apply) .(Fill all that apply) <br /> � r <br /> Active 9 Passenger Generator 0 Outdoor <br /> GPs Latitude 0 Q Closed Q Altered <br /> Q Hauler 0 Indoor <br /> D Inactive Q Trude <br /> Longitude <br /> too <br /> PlannedQ OTR End Use Q Container <br /> Business Type (FII all that apply) - - — - <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet A Govemment 1Q Retreader 0Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture Q Shredder Q Other <br /> _ _ I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility r'r: <br /> O 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 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 CGR§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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Com <br /> men <br /> ts G l L 34!�Er-f/ V <br /> 7-1 <br /> Inspection Form included:Q <br /> Comments Included:Q - <br /> IS sines,R 's Signature Phone Number _ 981 natu _ Phone Number <br /> ■ INSTRUCTIONS ON BACKNoWaRNM R A M P 1- E 12 3 62081 <br /> White Copy:CIWMB Yellow Copy,.Operator Pink Copy LEA ® ■ <br /> 0711604.0115 <br />