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�p Waste TiretWey & Inspection Repq# Inspection Report Number <br /> State California Survey Form - Page i 6 - 1 x 6 3 2 3 <br /> C14VMB 181(New 04104) <br /> Callfornia Integrated Waste Management Board <br /> Part A- Su, rveY _ _ _ BLUE OR BLACK INK PEN <br /> 1tBuslness Profile Inspection Detalls _ — <br /> TPIR Inspection Type (Fill one) <br /> Site Suffix: 4 © '7 ( I a Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ,� If Referral,choose referral type(Fill one) <br /> Identifier: ri 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - <br /> �/� Inspected By Inspector <br /> Physical Address G] / <br /> Inspection DateO / / .-7 Z, / <br /> �G J Time In (� Timlee Out <br /> Business Rep Title Q AM Q AM <br /> QPM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Vlfhale/PTE� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> t ? j Active 10 Passenger ® Generator l*Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude <br /> 0 0 Inactive � 0 Truck 0 Hauler 0 Indoor <br /> Longitude- .. 10 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dexter Q Auto Repair 0 Trucking Fleet 0 Government Q Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body ID Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> � . Jiiil/ixi� <br /> %i%//, <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§ 11459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 +14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers / <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities ' <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § <br /> Comments n r <br /> Inspection Form Included: Q �` � I / COOV <br /> Comments Included: Q165-4-) o - <br /> Bus a Phone Number Insp r s,Sign re Phone Number <br /> A <br /> / - -62081 <br /> INSTRUCTIONS ON BACK yti E A> P L E 2 3 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />