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Waste Tire Survey & Inspection Report Inspection Report Number <br /> s'e`en181(Nnia Survey Farm - Page 1 1 1 . 1 0 3 3 3 <br /> CIwMa 181(Now 04/04) <br /> Calitomia Integrated Wasfe Management Board <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Businessfrofile Inspection Details - - -1 <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: / * 7 ` 7- 1 S Q Routine i Re-inspection Q Referral Q Observation <br /> Local �.r+ If Referral,choose referral type(Fill one) <br /> Identifier. �j ,,ems� -�Y Q CHP Q CIWMB Q Complaint-Q Educational Visit Q Other <br /> Buess or Facility Name —-„��V- Inspected By Inspector <br /> Business <br /> Physica Address <br /> / , Inspection Date 0-7 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Jti, - <br /> Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> e � , Q� <br /> •Active 0 Passenger 0 Generator le Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - End-Use Q Container <br /> Q Planned Q OTR Q <br /> Business Type (Fill all that apply) - <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> •Used Tire Dealer Q Auto Body Q 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 s <br /> a <br /> Q 1 O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> i p <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> w <br /> Q Q 14 CCR§18459 -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 14 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 1 Q 1 Other: § z - - <br /> Comments e..1t�'� L S 4� — <br /> �' p" - —rj,-mss is - rr��sh.•.� �Q�/�,r, <br /> S, A-5 <br /> l Sao Si�-�- ��,�-• J s '�-. � �ct..s Utv9.,�t'�. �-esa1�GQ. <br /> Inspection Form Included: <br /> Comments Included:Q d P ber io4relssl PhoZne9gG <br /> Ntmtber_ <br /> INSTRUCTIONS ON BACK X a M P L E 1 2 62081 <br /> ■ 0716504.0110 White Copy CIWMB Yelinw Copy Operator Pink Copy..LEA © ■ <br />