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r <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stale California <br /> CIWMB 181(New 04104) -Survey Form Page 1 15 - 1025652 <br /> ' California Integrated Waete Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- + ! 3 � _ Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: w 1l ^ �N j� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> A J p�i�lnir. M✓� y .../ <br /> Business or Facility Name Inspected By Inspector <br /> ZIcal Address � � 9 1 © f �••,,•�'7�gq�Gt�s <br /> 215-2 -2 W Uel <br /> 'e: e_CAI Inspection Date <br /> C� 9533 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0P 0P <br /> Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active Q Passenger ' Generator 0 Outdoor <br /> (gip$ Latitude <br /> O Q Closed Q Altered 11 <br /> Q Hauler Q Indoor <br /> O Q Inactive ® Truck i <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> I � I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair •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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility .N INT TATUS_____ <br /> q+l HA f�f�AND-M IFIEST--R QUIRRIVIONT8 <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ' ViCl.e on 0 EXtpn I <br /> Q Q PRG§42953-Contracts with Registered Waste Tire Haulers. q <br /> - OsAdii�e <br /> Q Q PRC§42956-Registration/Decal in Vehicle r <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 II "�II 7711 <br /> Q Q 114 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> df rNOif:gr <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - <br /> Q 014 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers } IE1fb(ftlilL� <br /> r <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities r <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators E �Y � I � <br /> Q 0 <br /> Other: § p -'✓'v �� <br /> Comments <br /> j ''//� <br /> T C�2 � G�-- -- � a, i f�+ G�OGS <br /> h�"�" Z>,( ti.1��-� 't I✓'e- /t�-���.t1�L S't 5 y <br /> Qa�►— q r'C'a- -t- r iC_ 42 <br /> Inspection Form Included: Q <br /> Comments Included: 0 /ss <br /> Businature Phone Number Sign Phone Number <br /> 62081 <br /> INSTRUCTIONS ON Aav� EF�� 2 C 3 <br /> Entered <br /> KB White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />