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=_ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of Survey Form - Page 1 1 3 - 1 0 1 3 6. 7 1 <br /> CIWMB 181(New 04/04) <br /> CalNomla IntegragrateddWaste 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:. D 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifler: s toR��,,�, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> Y Inspector / <br /> b�p <br /> Physical Address I 3 9 — / Q / S(,68/3 117VI <br /> (LI8/3J7V! <br /> "?3D3 /!i ✓� <br /> S' c, f 9S f Inspection Date 0 <br /> Time in Time Out 7� <br /> Business Rep Title O •AM <br /> L _D Q / O AM <br /> / : / O PM / .36 O 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> d <br /> O Q CloseQ Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned 0 OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government (5 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 Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires , <br /> O 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 /> 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 s r r <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ;; t <br /> r <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 ,'�� Cd`� Q � � <br /> K/94,,;C }l?xd Ac! f`' - - OS&C 694 <br /> I^.e D <br /> Inspection Form Included: op <br /> GG__ ---- <br /> Comments Included:Q Llama-vVew Fes'✓e <br /> Busi ass Rep's Signa r Aw <br /> Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK 1IEjXjAjMjPjL[ELTj 2 3 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0624904.0174 <br />