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=e, Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StateotCallfornia Survey Form - Page 1 1 7 - 1 0 1 3 6 6 7 <br /> CIWB 181(Now 04104) <br /> California IntegratMetl Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection 0stalls <br /> TPID- <br /> Site Suffix: Inspection Type (Fill one) <br /> / / - Q <br /> 0 Routine QRe-ins Re-inspection <br /> Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier fall- y Q CHP <br /> Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address - <br /> 3y Io / <br /> nA Inspection Date <br /> S� <br /> `/,7 Time In Time Out V <br /> Business Rep Title ` OAM O AM <br /> Q,1 l U 0 PM 9 PM <br /> /,/ operational Status Tire Type Business Role Storage Type - <br /> Tire Count(W hole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _ t t / 0 Active 0 Passenger 1*Generator *Outdoor <br /> O0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude _ End-Use Q 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 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 0 Agriculture Q Shredder Other �"moi Q <br /> Part B Inspection of Waste Tire Dealer Generator Hauler and End-Use Facility <br /> iyta <br /> ^S,z{�Y'�ig°^ 3`•.'j <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 /> O O I PRC§42956-Registration/Decal in Vehicle r r <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 daysWorm <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years r:: w <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other. § - <br /> Comments <br /> Ofai'44-A01, <br /> Inspection Forth included:Q fcor— <br /> O vi <br /> Comments Included:Q -- �^� <br /> 88 Rep's Signature Phone Number Inspector s Signature Phone Number <br /> INSTRUCTIONS ON BACKX A Nl PE X P�J 1 2 31 Z 3 62081 <br /> ■ While Copy:CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br /> C1624904.0171 <br />