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aWaste Tire Survey & Inspection Report Inspection Report Number <br /> State CrWMB 181INCalifornia Survey Form Page 1 1 6 1 01 3 1 8 T <br /> CIWMB 1e1(New nage <br /> California 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: / _ O 0 Routine Q Re-inspection Q Referral O Observation <br /> Local (� If Referral,choose referral type(Fill one) <br /> Identifier: J2it_ �Qd.,�2j O CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name (�'� <br /> aa �,/� Inspected By Ins ec,tofj <br /> f /OW1 A G0- .r4 <br /> L,4 <br /> Physical Address O <br /> Inspection Date Q / O �'7 <br /> B�y L7l 7 Time In Time Out / <br /> Business Rep Title Q AM Q AM <br /> QPM - QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> T ' ®Active ®Passenger Generator 0 Outdoor <br /> 0 O Closed 0 Altered <br /> GPS Latitude Q Hauler Q indoor <br /> O Q Inactive 0Truck <br /> Longitude — 0 Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer •Auto Repair Q Trucking Fleet Q Government Q Retreader 0 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 0 Hauler Q Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q 0 'PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 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 /> O 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments )at eL/�1r W QyQ/ 944-e i w7 Az't a <br /> Inspection Form Included. <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0711604.0167 <br />