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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stale of California Survey Form Page 1 2 - Q 0 6 4 0 2 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / 6t! _ D Inspection Type (Fill one) <br /> Site Suffix: N7 "7 46 Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical <br /> 701 <br /> Inspection Date / 6 I 0-5 <br /> � 533a <br /> Time In Time Out <br /> Business Rep Title O AM O ANI <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active O Passenger 1 ! Generator O Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude O Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder O Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility _ENFORCEM NT STATU8._.._..__..._.,...___ <br /> A I HAULIN Iij0 MANIFEST R11IfIRE"MENTB Q Nptics'Of.--... ne1*tion Q Extrnslon <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C o.Mollon'491 eadline <br /> i <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q Q I14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements pate <br /> O I O 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CfWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Reqt k+sd for NOV or EXT) <br /> Q O 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 Harders Q ROfOrred!,CIWMB Enforcement <br /> Q O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other. § <br /> Comments 'l S tdr`•�e.V . �� �`�WMf�,��+�1$ V\.a1�f;�, <br /> a5 f`Cf �lln C__J ' 6 � Ct-C i 1I`/ <br /> (J/7/ 2•,le, <br /> Inspection Form Included: Q <br /> Comments Included: Q - - - <br /> us no.. <br /> Rep' Signature Phone Number no Number <br /> i <br /> INSTRUCTIONS ON BACK E l 131 YRf'� '.lli� (jy�/i. L <br /> :-T <br /> I 2" 3 62081 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> Entered <br /> KB <br />