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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CIWMBKalifornia Survey Form - Page 1 i 1 - 01 3 3 $ 9 <br /> CONMB 181(New 04104) <br /> c"fomia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / I g 9 d e Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: OCHP OCIWMB OComplaint OEducational Visit O <br /> Other <br /> Busies_ocility <br /> •• Name Inspected By Inspector <br /> `Gt d <br /> Physical Addre <br /> 121 S i,�a•-r<ar/�o - <br /> Inspection Date ? © -7 Q 10 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Tti/Burs ©L", - <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 /> S •Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude <br /> O 0 Closed 0 Altered <br /> GPs 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned ®OTR O End-use O Container <br /> Business Type all that <br /> YP (Fill aPPIY) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 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 /> 0 O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 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§18459.3-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 <br /> was <br /> Inspection Form Included:0 <br /> Comments Included:0 C,14- � ' _ � g <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK IIMI p 1,I El 111213 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0609004.0054 <br />