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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> Cli 181(New 04104) Survey Form - Page 1 1 5 - 10 0 6 5 5 3 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- Inspection- O l Inspection Type (Fill one) <br /> Site Suffix: / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sQ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> / Q Inspected By Inspector <br /> Physical Address 3 9 ✓ / 5���F�}A0 <br /> Inspection Date (J <br /> Time In / Time Out <br /> '� <br /> Business Rep Title��/ / Z O / (/ . � `Y �AM <br /> PM <br /> O PM <br /> Operational Status Tire Type Business Role Storage Type. <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 7 *Active Q Passenger 0 Generator •Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 40 Truck <br /> Longitude - Q Planned IS OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 /> LQ Service Station Q Hauler Q Agriculture Q Shredder ®Other FCLf/�f t��•,��r,,(r...�� <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility1WNF L6EMENT STATUS <br /> V A HAULING AND MANIFEST1k S <br /> -- - - - - - - - -- ---- 0 Notice Of Violation Q Extension <br /> 0 0 PRC§42 351 -Wriste Tire Hauler Registration and Transport of Tiles - <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. ,CQmp{iartce DeadiiAe <br /> Q Q 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 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years b r , r•; <br /> Q Q14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers fCi <br /> Q O <br /> 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 /> -� 4tS'ti�a AAb-� ib� a <br /> Q Q Other: § <br /> Comments 10 r10, �'y•'` +oN %/"< i'� /aet�e�y P t� <br /> Inspection Form Included:O <br /> Comments Included; <br /> Business p's Sig a re _ Phone Number Inspector's Signature _ Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPI 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />