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■ 581 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California Survey Form - Page 1 1 3 - 0 1 3 3 1 7 <br /> CIWMB'"(New 04104) <br /> California IntegratedWaate Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN_ <br /> Business Profile inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suf x: 2 3 1-t (� 4" - ( Q Routine ®Re-inspection Q Referral Q Observation <br /> Local B Referral,choose referral type(Fill one) <br /> Identifier: a^� ul�— �1►`f iGH� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - <br /> Inspected By Inspector <br /> Fes- 0". 4'4,5 <br /> _ <br /> Physical Addrep / o <br /> 2G> O f x,4-0,- 124 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Rola Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger ®Generator •Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet Q Governmento 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 /> - <br /> ', <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> E <br /> Q Q PRC§42956-Registration/Decal in Vehicles <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 Q 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 t <br /> Q Q 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: § nn ) sr « <br /> Comments Z-4jjP..4 rV 't2ro, a/ <br /> f Cr„ etwl4l� �_ <br /> �l Its ��_ <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Si nature Phone Number I ectoes Signature _ Phone Number <br /> INSTRUCTIONS ON BACK IE XAMIPII 0 Ill 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0615104.0725 <br />