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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateor'W"fstrnie Survey Form - Page 1 19 - 1 0 1 3 1 7 3 <br /> CIWMB 181(New 04/81) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- Inspection- Inspection Type (Fill one) <br /> Site Suffix: / 7 / / 3 0 / 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> esti S, �� � If Referral,choose referral type(Fill one) <br /> Identffler Qn Q CHP Q CIWMB Q Complaint Q Educational Visit O Other <br /> Business or Facility Name <br /> / r--, Inspected By Inspector <br /> Physical Address <br /> Inspection Date C)_2 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM 0 PM <br /> operational Status 'Tint Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f"O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J 0 Active t♦Passenger 40 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � Q Hauler 0 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 /> 0 New Tire Dealer 49 Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O 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 /> O O 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 /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System.Requirements for Registered Waste Tire Haulers <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q 1 Other: § <br /> Comments Age,;&,* ZVey /'P�iG 1 �/�2' Sri /��fiQ✓e >'},-j <br /> 5�%"y OSS �:� � Y`s 2�+.e � i 6y�--➢'��• %�%t �u'��y7^oi..•s <br /> 121-11,10 IzeloeAvle-ewl 11,,14 A-,10e-lIIl ZZ--Y. <br /> Inspection Form Included:Q T �1/ ,1 I Q <br /> Comments Included: <br /> .Business Rep's:Sl natu . Phone Number Inspector's Signature' Phone Number <br /> INSTRUCTIONS ON BACK JEWAIMIPILIE162081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0708104.0045 <br /> N_. <br />