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u Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWM of California Survey Form - Page 1 1 6 - 1 0 1 3 3 2 $ <br /> CIWMB 181(New 04104) <br /> Califomla Integrated Waste 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: ` —70 O - 01 Routine Q Re-inspection Q Referral Q Observation <br /> Local Qr ur ,�+ � If Referral,choose referral type(Fill one) <br /> Identifier: �N� j IQCHP Q CIWMBQComptaint <br /> Q Educational Visit <br /> Other <br /> Business or Facility Name Inspected By Inspector <br /> �fA11 i ll 9 �3-ar '1.3ac is <br /> Physical Addressddress 3 - C <br /> (0444- t1l 01werl7 12DJ <br /> Inspection Data <br /> L;• ., C,4 R 5�•3 b <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 0 PM 0 PM <br /> - <br /> Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' 2_ 00 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ®Active ®Passenger @ Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ®Container <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 Q Agriculture Q Shredder 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 Other: § <br /> Comments ►►`` ! (�-e.; Q�-G �r7t/�rX ��i �nSTY .tC�L�.!�..._. ��'f1'�.�_- , {�G(/\I'�S <br /> qw <br /> l or c�v-G 'f ir-g� <br /> Inspection Form Included: Q . p G <br /> Comments Included:Q / 4Y1 7. 3 C'4O 7 g"^"`� <br /> Pu. ess R.W. Signature Phone Number Ins or's Signature Phone Number <br /> INSTRUCTIONS ON BACK IMIPILIEI 1112131 <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0603104.0168 <br />