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Waste Tire Survey & Inspection Report Inspection Report.Number <br /> State of California <br /> CIWMB 181(NewSurvey Form as Page t .f 9 - 1 01 3 .719 <br /> California Integrated Waste Management Board - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details,. <br /> TPID- ^ 0 - „ ( Inspection Type (Fill one) <br /> Site Suffix: d� ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SRI - 1�rY j n cinAlKt(/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other . <br /> Business or Facility Name- . .. . 7 T1 <br /> (� Inspected By Inspector <br /> Physical Address 0 <br /> Inspection Date I (n <br /> A' 4,L,-e coL_ 953346 �r <br /> Time In Time Out <br /> Business Rep Titles 0 AM <br /> riCa+� 4-tawe D a 3 0 0 P O 3 O ® ®PM <br /> - Operational Status Tire Type Business Role Storage Type - <br /> Tire Count(W hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> O @ Inactive Truck <br /> Longitude - Q Planned ®OTR Q End-Use Q Container <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 Other Paan r MaK Ltfodkrlho <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 42951-Waste Tire Hauler Registration and Transport of Tires e ' <br /> Q �Q PRC§ 9 P <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. ix <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 /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q 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 /> 1010 1 Other: § <br /> Comments I IU t W1 Ka 'nepI <br /> r <br /> &L noft art A tt rs os-ed aA Sa td 6 ranoL n 2 w, 110 W ae-c- <br /> Iaj!z r 1" <br /> Inspection W1. included:Q ) <br /> Comments Included:Q <br /> Business a ( ~ <br /> s Rep's-Sign Tre ' Phone'Number Ins r s.Sig e.'. Phone Number. <br /> INSTRUCTIONS ON BACK [EI JAIMIPILIE1 <br /> 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA - ■ <br /> 0605204.0581 <br />