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■ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> MI of California Survey Form - Page 1 1 4 - 1 0 1 0 7 3 6 <br /> CIWMB 181 Waste <br /> nage <br /> 4104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j ^ Q Inspection Type (Fill one) <br /> Site Suffix: 1 aC a - Q // <br /> if Routine Q Re-inspection Q Referral Q Observation <br /> Local � ��/� If Referral,choose referral type(Fill one) <br /> Identifier: �p C� — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Road � gess 3 q - <br /> Physical Address <br /> 3 3_3 L orjm,�_s <br /> StC-[vI-) C� gsao5 Inspection Date D S / <br /> Time In Time Out <br /> Business <br /> J�Rep <br /> �/ n Title Q AM O AM <br /> If VG FZ(i{�f�- Ar -- • O PM O PM <br /> - Operational Status Tire Type Business Rote Storage Type <br /> Tire Count(Whole/PTE) ,�y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> p Q Passenger *Generator *Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude j Q Hauler Q Indoor <br /> O OEED <br /> ®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 <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> ... T^ <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 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 O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years s. <br /> Q O 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 s` < _ 1 W110 'M <br /> '`` ' <br /> Tsar^ x .'n <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments �I1 S �.y2 7D'>' aS ��LJ�o ` r <br /> IU s less fan n,u�eTf P.t.f�s4jazs�� Acs W Saer m"Lly f <br /> achir ItivoiCts UivatoL fir- d, t,/io La ,f� 'ed, <br /> .Inspection Form Included:0 p <br /> Comments Included:Q 2 1 r <br /> usiness Rep's Signature Phone Number __ I s ctoes ' nature Phone Number <br /> INSTRUCTIONS ON BACK "�1� ,q p f 62081 <br /> ■ Yellow <br /> I o © ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />