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jMWaste Tire Survey & Inspection Report Inspection Report Number <br /> Slate nlCa rornin Survey Form - Page 1 1 6 - 1 0 1 3 1 9 5 <br /> BIW ti 181(New 04/04) <br /> Cal Momla Integrated Waste Mana9emenl Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Debits <br /> 7PID. / ! p � / Inspection Type (Fill one) <br /> She Suffix: 3 f y a 7 oD I 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local l (12 If Referral,choose referral type(Fill one) <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> //JJ Inspected By Inspector <br /> P esddress .3 9 <br /> c7 Inspection Date 0 7 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> �A�ntD �r i O PM O PM <br /> Operational Status Tire Type yps Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Flt all that apply) <br /> ! r 0 Active Q Passenger a Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � Q Hauler Q Indoor <br /> O Q Inactive *Truck <br /> Longitude — Q Planned Q OTR I Q End-Use Q Container <br /> Business Type (Fill ail that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O 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 O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 10 1 Other: § <br /> Comments <br /> 7 C. >� / •sere w�1� 7'R3. �i1L �1 V:.rw a.( c�A 9,� <br /> N4)1`1 <br /> "VP <br /> All, <br /> Inspection Form Included:.0' <br /> comments.Included:01 � 9 <br /> u ep' <br /> iness s sl nature Phone Number nspectoes Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK jEjXjAjAkjPjLjEj 1112131 <br /> 62081 <br /> 8716504.0029 White Copy CIW?M Yellow Copy.Operator Pink Copy:LEA ® ■ <br />