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«a, Waste Tire Survey& Inspection Report Inspection Report Number <br /> staEs of CalNamla - SurveyFocm - Page 1- - I 3 - 1 0 0 6 4 0 3 <br /> CMMB 181(New 04104) <br /> California Integrated Weete Management Board <br /> artA-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 3 C / 3 O Inspection Type (Fill one) --I{ <br /> Site suffix 7 - 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name , <br /> Inspected By Inspector <br /> Physical AddreQs O y - \ <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title - Z Q AM Q AM <br /> 0 PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' r 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> (iPs Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude0- Planned 0 OTR 0 �End-Use Container <br /> Business Type .(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuet <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 ,0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-.Contracts with Registered Waste Tire Haulers. - <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§16459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0. 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Or' �y <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilitiesy <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other. <br /> Comments 7 -M s "'G T w� a /���Ar,\ e "t"l 1.. ( 't►/�S -t"k_ -—- <br /> I� � S�_ N� .!✓tt�TC ��l�,tS e�rJ'je Me-X„ Ia V�S� <br /> Entered <br /> Inspection Form Included:0 <br /> Comments Included:0 f'S5 7"1 <br /> B I ss e s Signatur Phone Nu r In Y;0 re Phone Number' <br /> INSTRUCTIONS ONBACK yA4�P(L�EE li� Ik 62051 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA <br /> 0529204. 1184 <br />