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Waste Tire SuReY p p& Inspection Report Inspection Report Number <br /> State of California S u rVe Form Pa e 1 - 0 7 <br /> CIWMB 181(New o4104) Y <br /> callfornle Integrated Waete Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> t <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � r•�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Ph slcal Addr ss / <br /> Inspection Date 0 0 3 S <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM O PM <br /> Operational Status 1 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> o ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude – Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 Other 1>_-,le,— <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFOROWNT STA' IJ$ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notlae Of. <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Violeticrt Q; ttl l ifF <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Camplf�lnce'D6poliRo 1 f <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 3 <br /> Q Q 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements Date m ' <br /> OHO 14 CCR§18459.1 a b c -Tire Program ID Number from CIWMB <br /> 14 CCR 18459.2.1 -Submittal of Manifest Forms and Tire within 90 days {Rsf�► OV, '�//i <br /> O O Trip P Lo s 9 Y <br /> Q Q 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 > Atbtltd-/fIgJISy <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O -- - '" <br /> Outer: § <br /> Comments <br /> Ct f C-4a .Ck <br /> 01,^5 r--gol.ie_ t7►-+g1''F�. /ja <br /> Inspection Form Included: Q <br /> Comments Included: Xe.'s Signature Phone Number In ctor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corp lnotafToct� :� !r X A:AIi P l 12 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />