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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br />State of California Survey Form - Page 1 i 2 -- 1 0 1 3 6 4 6 <br />181(New CIWMB O4104) <br />Waste Management Board <br />California Integrated <br />PartA -Surve BLUE OR BLACK INK PEN <br />- _--inspection, <br />Business Profile. Details <br />TPID -Inspection Type (Fill one) <br />Site Suffix: y y 9 - © 0 Routine 0 Re-inspection 0 Referral 0 Observation <br />Local,�/ If Referral, choose referral type (Fill one) <br />Identifier:- t/Lt.r y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />QO <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Address 3 9 / o / cr�,BQTy//wJyl <br />inspection Date 0 <br />U <br />D <br />Time In Time Out <br />Business Rep Title AM % . AM � <br />� � <br />0 PM / 0 PM <br />Operational Status Tire Type Business Role Storage Type <br />Tire Count (W hole/PTE) / <br />6) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />i I2 <br />0 Active • Passenger * Generator 0 Outdoor <br />0 Closed 0 Altered <br />GPS Latitude 0 Hauler Q Indoor <br />0 0 Inactive 0 Truck <br />Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br />Business Type (Fill all that apply) <br />New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />— <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br />~ '> ao. l <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 0 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days - <br />0 0 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years s� <br />14 CCR § 18460.2 -Manifest System Requirements for Registered Waste Tire Haulers � <br />0 0_ <br />x <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End-Use Facilities ,+�-° <br />~ L" <br />0 0 14 CCR § 18462 -Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 1 0 Other: <br />-§ <br />CommentsQ�^�' <br />G[, styrl /i' /gyp s»X.,/ � )4�y 6W a-9-"➢�, <br />- <br />%� �► ."r r��u.�.f�f rte.., �'� � � ��dl�S � <br />Inspection FormIncluded: 0 <br />Comments Included: <br />s , s Rep's Signature Phone Number Inspector's Signature, ; . Phone Number - <br />fl,+p'sr 62081 <br />INSTRUCTIONS ON BACK !; '" AMP C1 .2 3 <br />. White Copy: CIWMB Yellow Copy. Operator Pink Copy LEA ® ■ <br />0622104.0012 <br />