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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CIWMB181Cal(New Survey Form - Page 1 1 $ • 1 0 1 3 6 8 4 <br /> CNVMB 181(New 04!04) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- y / Inspection Type (Fill one) <br /> Site Suffix: 3 A � �6 6 � I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �7 If Referral,choose referral type(Fill one) <br /> Identifier. L4ZL �pQ�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Fa�ame, Inspected By Inspector <br /> Physical Address <br /> 09 <br /> /-.PC^� <br /> 30 Inspection Date © 4 / 2 06,- <br /> Time In / Time Out <br /> Business Rep Title (6 AM AM <br /> D 9 ' U 0 P ` © -7 <br /> 0 PM <br /> - - - 'Operational Status 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 /> t t •Active Q Passenger ®Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair i 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 /> y <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 x a <br /> Q O <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q ', Q <br /> 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 HaulersQQ <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilitiesr r <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators = <br /> Q Q Other: § / <br /> Comments FCLt/G rsj /L,()!C ;e,& v., v�e <br /> /+-'�! 4� 9��'c �k s�aocF lGi'�60+� Gft✓ �7i_ arty Qct <br /> it/-.r.-j a-re V-4< .4/.4 uV, <br /> Inspection Form Included:QWessRe <br /> � <br /> Comments Included:Qture Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK I EIXIAIMI p I(-I EI 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 0624804.0351 <br />