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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r State of CaOrornia <br /> CIWMB 181(Now O4!04) Survey Form - Page 'I .1 3 1 01 3 6 6 3 <br /> California Integrated 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: 3 6 9 7 9 0 40 Routine Q Re4nspection Q Referral Q Observation <br /> Local If Referral,choose refercal type(Fill one) <br /> Identifier: h Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Businp"r Facility Name ('7 Inspected By Inspectol, <br /> Physical Address 3 T – �l��L$�%�/�F�✓ <br /> Inspection Date <br /> O Time In Time Out <br /> Business Rep ,Q Title <br /> �e /JLt`h�J / / O PM n 3 O PM <br /> Operational StatusTi� Business Role Storege Type <br /> Tire Count(Whole/PTE) to <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ^ 48 Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned 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 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 0 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 Atlre Vibfatllp <br /> Q Q PRC§42953-Contracts With Registered Waste Tire Haulers. <br /> iJeac#liam <br /> Q Q PRC§42956-Registration/Decal in Vehicle , 1 " <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 k 4 <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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § ,, ,,� h "�� <br /> Comments e,4,Y d4ed "-& ka ��/C !/ '� d7✓/y �I J`l_. <br /> aw 14/L /�[/l7rl� �1Xe�_ 4 4X'4y,+ 4<.--LIrFYt e1�ep,st <br /> dcK/C4 �-r/� QI'! LCtO✓P/� _ -t—��r ... _�R <br /> i V— <br /> � � <br /> Inspection FormIncluded:Q <br /> Comments Included:Q <br /> Business Rep's.Signature Phone Number Inspectors Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK firXTAIMIPILIE162081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 067147N4.6269 <br /> r <br />