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Inspection Report Number <br /> Waste Tire Survey & Inspection Report ■ <br /> r State of California <br /> CIWMB 181(New 04104) <br /> Survey Form - Page 1 fi - 1 7 0 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Buslne_s_s Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 g 0 t) f Routine Q Re-inspection Q Referral Q Observation <br /> Local .If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector r <br /> IL <br /> Physical Address — 1 l'7 �1(`Or� <br /> Inspection Date 6 4( Z p <br /> Time In Time Out <br /> Business Rep Title +9t-,T, 1 O AM O AM <br /> ' J- - Q PM O PM <br /> ONO.,, ;Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) -p <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ,� <br /> ' ' ®Active Pasl�ger-._,-� Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — O End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 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 ®Otherrt <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility RNFOR <br /> A: +IAWt40M. D M*FRS*-RRaUIRIMENTS MQ Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires i�., <br /> /. / <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. ' ' 'r/i�'✓/'%� <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Dafitlt � Z q 5 0 i , <br /> O O 14 CCR§18459.1 a b (c)-Tire Program ID Number from CIWMB 1 <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years i,�r' Ns'�ii�� %�•� ����/'`//����, <br /> O O <br /> 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 O 'Other: § <br /> Comments R-LL y ->j t T1q t s 45l 6 l-f$4i,> 0,. <br /> IN t) W a'9-'LaY-L N'AtYwtt 'tr.� S S fb u <br /> 1Nk. 3 <br /> Inspection Form Included: Q <br /> Comments Included: 1 <br /> s Ign ure Phone Number Inspe or's Slgnature Phone Number <br /> INSTRUCTION N BACK`_ ,� R.X M F Lir 11 12[13 1;2061 <br /> � �� <br /> ■ White Copy:CI 8 Yellow Copy:Operator Pink Copy:LEA <br />