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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWMB 181 <br /> 81(Now <br /> Survey Form - Page 1 14 - 1 0 2 5 8 8 2 <br /> CIWMB 187(New 04104) <br /> Califomla integrated Waste Management Board <br /> Part A--Survey BLUE OR BLACK-INK PEN <br /> Business Profile Inspection Details ~ <br /> TPID n n 1 Inspection Type (Fill one) <br /> Site Suffix: j C•r (1 f ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral, choose referral type(Fill one) <br /> Identifier: (SAYE,�QCiG� t �(�U v �{ Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name (� Inspected By Inspector <br /> f'hysicaf�ddress 3 '" I �Mt'A-1, wC7-- <br /> g i yosP441;ie, <br /> Inspection Date � L�• / d � � O <br /> f l Time In ` Time Out <br /> Business Rep Title C) AM O AM <br /> ',SQPM QPM4t}vt,�f� -- _ <br /> JOperational 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 /> t ' ® Active it Passenger ® Generator ® Outdoor <br /> O O Closed O Altered <br /> GPS Latitude 0 Hauler O indoor <br /> U 1 O Inactive O Truck <br /> Longitude - O Planned 0 OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer t@ Auto Repair 0 Trucking Fleet 0 Government 0 Retreader O Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body O Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler O Agriculture Q Shredder 0 Other <br /> I <br /> - <br /> .Y HAULING AENE�2RCM�T� �t'i STAT. U �` <br /> Part B - Inspection of Waste Tire Dealer Generator Hauler and End-Use Facility <br /> - / <br /> AND MANIFEST REQUIREMENTS �tl >attafi�l <br /> O 0 0 Nbe Of VIdletlon q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Gompllenep # AdIJlIs ,�` <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements p �' <br /> 14 CCR§18459.1 a b c -Tire Program ID Number from CIWMB m <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ,.' 'r':- <.'' "i�s,•fi ; , amu ' <br /> h § <br /> f�i <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 .#�:•:r'c:<>�;`.::-:� .::.,.5;::;=3..;��?�"� ' r <br /> O O 114 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators h " NQ <br /> O , O Other: § <br /> Comments ��� vUS'1�, L A k 1 N - (,a !S Ila(it ti/Q fires e arlv'- W <br /> if L C*-eIli J <br /> a � J . Tres S�✓� s See r 1 u�,�L 6,.,l41� VI,b cifi' +vz& <br /> ti Me . <br /> I <br /> Inspection Form Included: - qp <br /> J - - __ - Numb <br /> usin p's Signature Phone Number <br /> Comments Included: Q !n pector's 'gnature Phone Number <br /> 62081 <br /> INSTRUCTS ON BACK CorFBGtw _Inaoirmct : ( ?CAM L E; 1 2 3 <br /> �_ _:_ _ <br /> paleJU3 White Copy CIWMB Yellow Copy:Operator Pink Copy LEA <br />