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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIwM 181(Californla Survey Form Page 119 - 1008090 <br /> CIWMB 181 stew nage <br /> 4104) <br /> Callrornfe Integrated Waste Wanagement Board <br /> Part A-Su_rv_ey __ .-BLUE OR BLACK_ INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- 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: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other 1 <br /> Business or Facility Name <br /> G�, }�,�..� _ Inspected By Inspector <br /> Phy�al 01dVr se sp ,{ , f � <br /> Inspection Date i b i Z / O 4 <br /> ' Time In Time Out <br /> Business Rep Title O AM O AM <br /> Cw _ O PM O PM <br /> N,A- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 5o <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Flll all that apply) <br /> ®Active ®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 /> 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 ® Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Statlon Q Hauler Q Agriculture Q Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> �1�� ;�11•���r��l,�!.': ��Ys�IbMi3�l.1..1#;It7 �i /9'�� Sq �! 4'./. s�L't/>',. yf.t 's5�ij�/G' ��/'-�',',�';, <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 /> 42 956-Reg ..i. ;. <br /> Q Q PRC§ Registration/Decal in Vehicle r <br /> �i/,, '"� <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements r' <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number frorn CIWMB <br /> Q 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 <br /> Q O 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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § 11a�_:ri/r <br /> Comments ,k•o�'.�'. oh}.X�c � 7 W IrS�''L �"�C�-S ��-�c�l.�� �r �P�rN� �U^r�l - <br /> �• .�-,��i(ic�__��- - (?•t-{.��-S � Vv�clwt i��� W�tnt�. ���?��.t��.2" C.cS u..q"I'c <br /> 61 LA L&7 <br /> - QA_ - I>A�IL). <br /> Inspection Form Included: <br /> OL <br /> Comments Included. — <br /> B Inness Rep Signature Phone Number Ins tar's Signa re Phone Number - <br /> ,.� ___ jEj 111213 62081 -- <br /> INSTRUCTIONS ON B ` y � �z' s E% A gA I W I L <br /> ■ While Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />