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a Waste Tire Survey & Inspection Report Inspection Report Number <br /> State B 181(New <br /> 1 1 . 1 0 1 0 700 <br /> GWMB 181(teMaage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A_ <br /> Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> site$ufflx: ` ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. SAA,7p C 'Ce 0 CHP QCIWMB QCom Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name <br /> M� TKK Cke_ Inspected By Inspector <br /> Physical Address 3 ITr ` ew u <br /> ll c V r t /�l�� Inspection Date V f / 7 / 0 <br /> v/S Time In 1 Time Out V <br /> Business Rep 2 Title ^A 1 Q AM Q AM <br /> 'Vtl�l7] p PM QPM <br /> U t <br /> Operational Status Tire Type Business Role Storage Type . <br /> Tire Count(Whole/PTE) � O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger *Generator ®Outdoor <br /> O I Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> LongitudeQ Planned Q OTR- Q End-Use Container <br /> - _ <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair le Trucking Fleet Q Government Q Retreader _Ql Dismentier 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 <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 /> O Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O 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: § <br /> Comments <br /> hr rfrea�( r `ce a h To- far uJagt� <br /> Inspection Form Included: ) <br /> Comments Included: thor <br /> e Rep s Phone Number Ins s g ure Phone Number <br /> INSTRUCTIONS ON BACK � i 62081 <br /> 2 � <br /> 0716504.0015 While Copy.CIW MB Yellow Copy:Operator Pink Copy.LEA <br />