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Waste Tire Survey & Inspection Report Inspection Report Number . <br /> sgrtarate `a°steM Survey Form - Page 1 1 1 - 1 0 1 3 6 2 9 <br /> CIWMB 181(New 04104) <br /> CMHomia Integrated Waste Managemenl9oard <br /> PartA-Survey._ _ _ BLUE OR BLACK INK PEN_ <br /> Business Profile _ - - Inspection Details <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: 7 Te .e 3 <br /> U Routine �Re-inspection Q Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> IdentMer: �QIL t 7e Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> PhysicalAddressC/ / i A <br /> /.2 3 3 3 -/ - - <br /> LQ yt rD Y S3 3� Inspection Date 061 / S C 6 <br /> P Time In Time Out (� <br /> AM Business Rep Title �1 a © - -I /'7 <br /> 10 AM <br /> �,y j.Q 6r x-e QLc V O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' n 6-- (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �( 0 Active ®Passenger 0 Generator 0 Outdoor <br /> Closed Q Altered <br /> GPS Latitude Q ClQ Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned O OTR Q End-Use Q Container <br /> Business Type (FIA all that apply) <br /> ------------ <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q 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 Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q 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 /> 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 Q 1 Other: § <br /> Comments FQ6�Q/ /- tea" (y� -1-e /ELCsQI e Lli�? e /� <br /> C'TL 's !ri'rw�c� c.�r-Ay /'��u�'c. ,��.nr��t -t-s' �Kd/�Qs�4 ►��-y <br /> Inspection Formincluded:Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK FET,XTAIMIPILIEI ! Z 62081 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> C1619404.11 <br />