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itBE9 <br /> Waste Tire Sur y & Inspection Report pspection Report Number <br /> Stateof California Survey Form - Page 1 Il - 1127508 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> ?art A-_Survey_ BLUE OR BLACK INK PEN <br /> Business Profile - 'Inspection Details - - - - <br /> TPID- , _ O Inspection Type (Fill one) <br /> Site Suffix: J <br /> y ® Routine O Re-inspection O Referral O Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: '�)m IJ � C O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> lye's39 - l O I 1 t I <br /> Physlc)I�ddr� m <br /> ^ Inspection Date <br /> La /(„� QSI Time In Time Out lJ <br /> Business Rep Title ) Q AM I n� Q AM <br /> {IPM 1� �✓ ® PM <br /> - - -- Operational Status Tire Type Business Role Storage Type <br /> all that app <br /> (Fill all that <br /> -- (Fill0 Active (FillQ Pass Passenger (®Genera orrIY) 40 OutdooraPPIY) <br /> Tire Count (Whole/PTE) <br /> � s <br /> O O Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive ® Truck <br /> Longitude - I Q Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> 1"10 <br /> , HAULING AND,MANIFEST 12EQUIREMENT.S'i <br /> 0o PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. r <br /> b <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements lq <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMBI <br /> I <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O Other: § <br /> Comments ,�., <br /> — <br /> Com e_ -- ( MPC 0-a o rkk <br /> OY <br /> Inspection Form Included: O 4Ames Comments Included: Rep's Signature Phone Number In c r' Signature Phone Number <br /> INSTRUCTIONSON BACK + ' Ei'Xfk"MjP1L1e1 1112131 <br /> 62081 <br /> White Copy: Yellow Copy:Operator Pink Copy:LEA <br />