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Inspection Report Number <br /> Waste Tire Sur*y & Inspection Report <br /> State of Survey Form - Page 1 t l - 0 0 6 Q 9 l <br /> CIWMB B 181(New 04104) <br /> Callfornla IntegrateQ Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details -- - <br /> TPID- C , Inspection Type (Fill one) <br /> Site Suffix: +� ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> � Inspected By Inspector <br /> Physical dress <br /> Z l <br /> So <br /> Inspection Date <br /> Time to Time Out <br /> Business Rep Title Q AM Q AM <br /> O PM QPM <br /> 1 Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ` o <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f J 0 Active 0 Passenger ®Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned —0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer t(Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body a 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 /> -•i• - - ��r�"r,,/% ,�%T• �r%iii/�•a✓i/ ///irj� �. ����� <br /> Qo <br /> icon-',- <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> i% <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> / <br /> , _ <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 ,� y _ <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 3tii t�i r <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers =s <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 i <br /> 0 0 Other: § - <br /> ., <br /> Comments .nl� VVI..5 <br /> �t_ <br /> dItAk C9> <br /> L"> <br /> ,,�o 001( c ,,5 <br /> ki rs <br /> Inspection Form Included: 0 4 `- <br /> Comments Included: Q `� -Z7 S <br /> B slness Re P at tre _ Phone_ Number_ Inspector Signature Phone Number <br /> r <br /> INSTRUCTIONS ON BACK �X A P L Y 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />