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«6` Waste Tire Survey& Inspection Report InsPection Report Number-. -� <br /> CW California Survey_ Form - Page 1 16 - 1006711 <br /> - <br /> CIWMBS181(New 0404) <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( Inspection Type(Fill one) <br /> Site SuHbc 3 0 (7 b b ®Routine Q Re-inspection Q Referral Q Observation <br /> Local rIf Referral,choose referral type(Fill one) . <br /> Identifier: 5 OL Y, ,O a 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - --- <br /> Inspected By Inspector ``-- <br /> Physical Address <br /> -5 PV pr. <br /> Inspection Date O � / 'L �j ! � <br /> Ute} Time In Time Out <br /> Business Rep Tide O AM Q AM <br /> (�� t, 3 ' � f WPM 4 Z 5 ®PM <br /> VVI"Yly <br /> Operatlonal Status Tire Type Business Role Storage Type <br /> TireCount(Whole/PTE) r (Fgone only) (Fill all that apply) (Fill all that apply) (Fill all dug apply) <br /> Active ®Passenger ®Generator Q Outdoor <br /> o O Closed Q Altered <br /> GPS Latitude , ' 0 Hauler ®indoor <br /> o 0 Inactive Q Truck <br /> Longitude - 0 Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder ®Other yAaj( Uwe-",- <br /> Part B-Inspection of Waste Tire Dealer,Generator,Haulerand End-Use Facility <br /> 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 O 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 is 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0. (P Other: § W ev.r <br /> Comments <br /> _(�/v�G��f1 <br /> ji a f2 A"A WIMt �1� 2&dnd l ikt ' 2 <br /> ,c <br /> ere <br /> Inspection Form Included:Q r dl <br /> Comments Includeda lti}�— 11A Lill 'A� ` <br /> Rusin s aforev Phone Number -Inor'a Sigdatuye Phone Number <br /> INSTRUCTIONS ON BACK X Ah.p E 1 2 ,�. 82081 <br /> ■ a � ae ■ <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0529'2' 14.0104 <br />