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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 15�- 1 01 31 9 4 <br /> CIWMB 181(New 04104) <br /> Cal'domWaste <br /> la Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details 1 <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: / 7 g t/ g 6 O <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Localnye If Referral,choose referral type(Fill one) <br /> Identifier: J 4t���� <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit <br /> Other <br /> Buiiin s or FacilityName Inspected By Inspector <br /> Physical Address a'313067-All *0 V� <br /> Id 4'0/ %. I ss <br /> 9�--236 Inspection Date O 7 / '7 <br /> Time In 1 Time Out / <br /> Busiin�ess Rep Title /+ 0 AM 0 AM <br /> 0 PM 0 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 /> 1 ' Active Passenger g ®Generator i Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauier Q Indoor <br /> O Q Inactive 10 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 Goverriment 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 Otherj�., <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 IN <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 <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 /> 00 Other: § <br /> Comments <br /> Inspection FormIncluded:Q <br /> Comments Included:Q <br /> Business Rep's Signa ure Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK p 12 3 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br /> 0711604.0118 <br />