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aWaste Tire Survey & Inspection Report Inspection Report Numberstat.of Califomia <br /> ClWMB 181(AManaga) Survey Form - Page 1 1 5 - 1013095 <br /> Cellfomla Integrated Waate Nanegement Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID' I / _ ' inspection Type (Fill one) <br /> Site Suffix: (P O 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� '^ QaQ \ If Referral,choose referral type(Fill one) <br /> Identifier: ` (,(L� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name U <br /> Inspected By Inspector <br /> Lits S�w�.b <br /> Physical Address je,& c_ LI-2, <br /> f f 1 3t) Inspection Date O a / O / O <br /> V� Time In Time Out <br /> BusiinessRep Title /��( O AM O AM <br /> inF)ry <br /> _t_a► �S 'L{/1 �'�, r`i r O PM O PM <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 /> f ®Active ®Passenger ®Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude ®Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned ®OTR 0 End-Use 0 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 Fuel <br /> ®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 Entitles Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 (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 /> 0 0 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 Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 i 0 Other. § <br /> Comments , L'A��4� ^�,,�„ - Yl ow .- t S -ted: 7 z5 f: �6� - <br /> s iN r2 W F `7�/, J(J <br /> e s- ' __T ✓i ff nTe o <br /> r s l¢- t $cy►,a1ct EjAe.�Ogred vie ide s '0)NWW46 dLla4s, <br /> fit- ` {mss I lutea _On �''fi L tts �s5 .. v' s <br /> 0 <br /> Io <br /> Inspection Forrn Included:0 <br /> Comments Included:0 � <br /> urine RepW1, e P one Number I ora S ure Phone Numtrer <br /> INSTRUCTIONS ON BACKX dkP (, ! 2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0708104.0073 <br />