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Waste Tire Survey& Lispeetion Report Inspection Report Number, =� <br /> r Stateo'wa5 <br /> Californiaornla Survey,Form - Page 1 1 1 - 1006450 <br /> CIWMB 181(New 04104) <br /> ca <br /> Integratd <br /> ed Waste Management Board - ------- - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> - -BusInese Preflle - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: h I 46 RoutineQ Re-inspection Q Referral Q Observation. <br /> Local if Referral,choose referral type(Fill one) <br /> Identifier: QCHP Q CIWMB Q complaint Q Educational Visit <br /> Other <br /> Business or Facility Name <br /> / Inspected By Inspector <br /> ..__. .rte .__ _— F - - <br /> Physical Address -" - f j - I Fi ' , <br /> Inspection Date <br /> c tn�e" I <br /> Lttti ,.t %:r <br /> ' Time InTime Out <br /> Business Rep Title i `O AM ! 0 AM <br /> 0 PM O PM <br /> 1 os cis cA --- <br /> ���~ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active ®Passenger ®Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler i Q Indoor <br /> 0 Q Inactive O Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> eNew Tire Dealer 40 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,Haularand End-Use Facility v <br /> Q O PRC§42951~-Waste Tire Hauler Registration and Transport of Tires & y { <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal.in Vehicle yw " <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days a ,i <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip.Logs for 3 years <br /> O O- 14 CCR§18460.2,-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities r <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O .Q 1 Other. § <br /> • �r <br /> Comments <br /> d1-.; s,r, a D <br /> Inspection Form Included:Qr <br /> Comments included:Q <br /> � � 35 6f8 <br /> Business Rep's Signature Phone Number_ p rgnature;' Phone Number <br /> ;y u, 62081. <br /> INSTRUCTIONS ON BACK -..• EJ JAXPILIE1 111213 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA ■ <br /> r=1525304.0172 <br />