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=<< Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateof <br /> 181(N.. Survey Form - Page 1 1 4 - 1 01 3 3 8 3 <br /> CBNMB 781(Naw 04/04) <br /> califomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 -3 e Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: oe 1r <br /> ►� C� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> P +11 <br /> Physical Address 3 grr�f l (<.0 psi <br /> GA Inspection Date Q 3 / Q o / 0 6 <br /> 95x:, Time In Time Out <br /> Business Rep Title O AM Q AM <br /> i <br /> O PM 0 PM <br /> – Operational Status The Type Business Role Storage Type <br /> (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> r r Q Active Q Passenger Q Generator Q Outdoor <br /> O ®Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that appy) <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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility °i ldii'II'' <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 1 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 Other: § L // <br /> Comments <br /> Inspection Form Included: --��qq <br /> Q ,�,,,/// <br /> Comments Included:Q – — `C YL– <br /> Business Rep's Signature Phone Number .E;wes SI atur� Phone Number <br /> INSTRUCTIONS ON BACK 62081 <br /> 1 xra��rt3� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 0615104.0742 <br />