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i<< Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California ns p <br /> CIWMB181(New04104) Survey Form - Page 1 1 6 - 10 2 5 6 1 2 <br /> CalltemlaIntegrated Waste Managementeoard BLUE OR BLACK <br /> Part A- Survey_ INK PEN_ _- _ <br /> Business Profile I Inspection Details <br /> TPID- QInspection Type (Fill one) <br /> Site Suffix: ?, U C� ® Routine Q Re-inspection Q Referral Q Observation <br /> Localt '✓ If Referral,choose referral type{Fill one) <br /> Identifier: �ljv." � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Phy icy al Address .3 <br /> Inspection Date 014 1 1 <br /> Time In ` Time Out <br /> Business Rep Title 0 AM Q AM <br /> L QPM 0 P <br /> v I CCS Prt6,je., T <br /> Fe4y i Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) } (Fill one only) (Fill all that apply)i (Fill all that apply) (Fill all that apply) <br /> d ® Active Q Passenger S Generator Outdoor <br /> Latitude Q Closed ! Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair • 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 ENFORCIrMsNT°#M.,, <br /> E V HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q NQtI�0f YlolbftOn a <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Catloglhtitae p�d�in4 -F " s ; <br /> Q O i PRC§42956-Registration/Decal in Vehicle ;'+ <br /> �Y <br /> Q Q 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements I V. <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 ' y y <br /> Q O 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 /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § z ' r:">vE - s, <br /> Comments <br /> f4Gfrn1 " / � rGC�y <br /> 1! <br /> �—-Pi��.Q,,, -5 f s �t�s� i <br /> !Inspection Form Included: Q <br /> Comments Included: Q <br /> Busines Rep's Signature Phone Number Ins p is Signature Phone Number <br /> INSTRIFQYU]1@�iQN BACK Cnfr9lit:_ �fl dfi'�CC: i E ) AMP E I 3 62081 - <br /> K8 White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />