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u Waste Tire Survey & Inspection Report Inspection Report Number <br /> Sbbed callf0Met.la Survey Form - Page 1 ! 7 1 01309 7 <br /> Cr MB 181(Naw 04104) <br /> Callfomla IMegretcd Wuta Managamaol Board <br /> Part A-Suryqy -- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: J .2 V ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalH R <br /> qu , eferral,choose referral type(Fill one) <br /> Identifier: Sw` vv w Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Fadlity Name <br /> y ,5 Inspected By f1 Inspector <br /> D <br /> Physical Address 3 - <br /> iy is wyWA4- <br /> 1,f )z � /1, 1533 7 Inspection Date O O ( � O 7 <br /> ✓�/��A^^!t�lf (�f / Time In Time Out <br /> Business Rep <br /> � f Title <br /> O AM Q AM <br /> O PM O PM <br /> R'efOW Lead c4alL(�i <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ,({ b (Fill one only) (Fill all that apply) (Fill all that apply) (Fig all that apply) <br /> ®Active P Passenger (&Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) —- <br /> IS New Tire Dealer a Auto Repair p Trucking Fleet Q Government p Retreader p 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 <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <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§184592.1-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 Other: § <br /> /Comments�a,,./ y n / F f 144 _s - . TO�� `Ol ,,tas �,6� TAAy -j �l <br /> uktS 7WWt 1!Tt"re �f Ivo-Si<. Are cLis� : 6U 5 ✓l4Ued v /GAJ TrLI K <br /> No _ '(n 0peAaA ns . U iol ct z'6vcs n . <br /> Inspection Form Included:p <br /> Comments Included: <br /> Q'Business Rep's gignature Phone Number In ors S Un Phone Phone Number <br /> - 62081 <br /> ■ INSTRUCTIONS ON BACK E X �l Ah P I L I El I 1 2 3 ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br /> 6708104.0075 <br />