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€, Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> atateof 181(Ne Survey Form - Page 1 1 2 - 1 0 1 3 2 41 <br /> CIWMe 181(New 04/04) <br /> California Integrated Waate Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details — <br /> TPID- / � �� � 4 _ O � Inspection Type (Fill one) <br /> She Suffix: -I-z7 <br /> / /// 7 4D Routine Q Re4nspectlon Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Ja4,�f���_�Q _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name —_--�`' <br /> /I Inspected By Inspector <br /> Physical Address ��- <br /> 23�0 � ��`�'�.—/r�o /� — f ill_//- ���"` — •[�-. <br /> Inspection Date D � / � � / Q^'7 <br /> Time In Time Out <br /> Business Rep Title O AM Q 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 appy) (Fill all that apply) (Fill all that apply) <br /> ' Q Active O Passenger Q Generator Q Outdoor <br /> O •Closed O 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 /> p New Tire Dealer p Auto Repair Q Trucking Fleet Q Government Q Retreader O 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 /> 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 /> Q Q Other. § <br /> Comments <br /> Inspection Form Included:Q <br /> comments Included:Q -y�`�f <br /> Business Rep's.Signature Phone Number62Waoesslonattu Phone Number <br /> INSTRUCTIONS ON BACK A ItA P L E 1 Z 3 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0711604.011-4 <br />