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■ e. Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> State of California Survey Form - Page 1 18 - 0 0 G 6 <br /> COMa 181(New 04/4) <br /> California IntegrNated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � - Inspection Type (Fill one) <br /> Site Suffix: d O 0 [( l ®Routine Q Re-inspection Q Referral Q Observation <br /> Lel If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> T rAL 9 t ( ` <br /> Physical Al dress [ l \ l fO�10 <br /> Inspection Date 1 C:) <br /> 1 •icy SS376 [ <br /> / Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM 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 /> f S Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> d <br /> Q Hauler Q Indoor <br /> QInactive r <br /> aQ Tuck <br /> Longitude OQ Plne <br /> Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ®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 /> s <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 8. <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> L ,J <br /> Q Q Other. § <br /> Comments <br /> / <br /> lid <br /> Inspection Form Included:Q / Cs 7, fjcP <br /> Comments Included:Q / !y/ <br /> Business Rep's Signature Phone tuber ,I p i _ Phone Number <br /> INSTRUCTIONS ON BACK f .x• 8 P L 1 2 $ 62081 <br /> ■ © ■ <br /> White Copy.CIWMB Yello Copy.OpFrator Pink Copy: <br /> 0600404.0032 <br />