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=1 Waste Tire Survey & Inspection Report Inspection-Report Number <br /> StatMINI or California Survey Form - Page 1 11 - 1006616 <br /> . <br /> CIWMB 181(New 114101) <br /> CalYomia Integrated Waete Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspectlon Detalie <br /> TPID- f 0 ' _ O Inspection Type (Fill one) <br /> Site Baffle 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local N Referral,choose referral type(Fill one) <br /> Identifier: &n On � <br /> ryO Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other !� <br /> Business or Facility Name ""(�,f <br /> Inspected By Inspector <br /> P�Physical dl ess Peo11 •�. -! - ' o L! �U l <br /> Inspection Date � � � � � � O <br /> Acawl P°/ R5 D Time In Time Out <br /> Business Rep Title O AMO AM <br /> Jt eS j S _ �oy QXa� l� r PM es O or <br /> � Operational Status Tire Typp e'_ Business Role :Storage Type <br /> Tire Count(Whole/PTE) �O O (Fill one only) (Filial[that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' O Active •Passenger 9 Generator. Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O End-Use *-Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) - <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q service Station •Hauler Q Agriculture Q Shredder (f Other Tro. w Ax le I{�^►' r 4:4a jI <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> IN <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires � �� <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. � d _• <br /> O O PRC§42956-Registration/Decal In Vehicle <br /> O Q <br /> lit CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c),Tire Program ID Number from CIWMB e f•. 1 ,.,, ` <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18461-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities V, I z 'z:" <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § p;.:. , <br /> fl <br /> Comments Rottil Ae- iKsped !6h *(s dau ayd -he Folio IJ as n Q f-ed B_ <br /> wash *ts am-sgrtoL_Y) 00door 004 and, e�i _ <br /> ri-C &Q ding ot,64 s a/ires6.l ja in ry,- <br /> irajer <br /> tnre.d S_ -Ir' s r f're. haul <br /> Inspection Forth Included:.Q <br /> Comments Included: <br /> -Q11 <br /> - - — <br /> usifiness Rep's Signature, hone Number I actor's' n ture - Phone Number. c <br /> INSTRUCTIONS ACK c '� w yk �y 62081 . <br /> SRI".P�S3: n l �� 15-ar 'lA rFf fL G `6 <br /> X31. <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy:LEA ® -� <br /> 0529204.0824 <br />