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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateof181(New <br /> Survey Form - Page 1 I - O i 0 6 2 0 <br /> CIWMB 181(New 04104) <br /> Callfomla Integrated Waste Management Board <br /> Part A-SUrV BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details —� <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I ' O 60 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: wwQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 3 '81S Tru $ <br /> Physical Address I - ` D I F,77 'O <br /> L0inspection Date <br /> Time In Q Time Out (J <br /> Business Rep ^ I, Title <br /> 1, O AM Q AM <br /> �^"� �riLr 1 LN/L /" QPM QPM <br /> F r(�y'j,V6co / 1, Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 f ®Active Q Passenger 0 Generator •Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill ail that apply) <br /> 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> f I' y'^tS3 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> s` <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. a <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 azasw <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ? r� <br /> Q Q 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 � �.- f <br /> Q O <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 01 Q 1 Other. § <br /> Comments kS b. jZs 6Jja Q.%%e_&I �X A �j <br /> ` c <br /> ` wa*' W' Y' -WA Fl ut WriE <br /> _ rt�ovv &w sr w ire a A <br /> iQlnS <br /> Inspection Form Included:Q <br /> Comments Included:Q +� I <br /> B I Re 's Signature Phone Number 1n oes g ature Phone Number <br /> INSTRUCTIONS ON BA K � � P L E D 2 62081 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy LEA © S <br />