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N 00 <br /> ----------- - <br /> =L= Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> rrr <br /> CIWNI r181(Nnia Survey Form - Page 1 1 5 - 1 0 1 3 3 7 6 <br /> Cgrale 181(New04!04) <br /> Cali}omla Integrated Wade Managem°nt Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: f 3 7 0 7 16, 8 Routine Q Re-inspection Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier. r► ��°Her �fiy � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> ,�-� Inspected By Inspector <br /> Physic( ddr;e�_ss 5�_ l 3 9 _ p 1 6,0zff 0g�l�tS <br /> Z3Z�1 E l„��,-F4 goo 12-X <br /> l�S 1 Inspection Date D <br /> Time In Time Out <br /> Business Re/p� Title O AM O AM <br /> 0P 0P <br /> — - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2— (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t t t'Active ®Passenger Q Generator 9 Outdoor <br /> Q Closed Q 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 /> Q New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ®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§16459 -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 114 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 /> 544, 5 <br /> Vi6-v—oyj G.k Jc')"r4- -'r i.ar 9 r,I"e. <br /> eA-) tr-o <br /> Inspection Form Included:Q <br /> Comments Included:Q13d <br /> Busines ep's re P Number Ins ctor's Sig ature Phone Number <br /> INSTRUCTIONS ON BACK E X AIMAIMI P IL I El <br /> 62081 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0609004.0350 <br />