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dWaste Tire Survey & Inspection Report Inspection Report Number M <br /> State or California Survey Form - Page 1 1 2 - 1 0 0 6 7 4 9 <br /> CMMB 181(New 04/0.1) <br /> calvomia Integrated Waeto Management Board <br /> PartA Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix:* 1. / ? ? 9 *Routine Q Reinspection Q Referral Q Observation <br /> Local <br /> � � �� If Referral,choose referral type(Fill one) " <br /> IdentNler. ap —(� p — C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name VD Inspected By Inspector <br /> � <br /> 39 - l b I �e ku� <br /> Physics Address <br /> lOSb <br /> r D <br /> Inspection Date <br /> V 1 <br /> Time In Time Out <br /> 41 <br /> Business Rep Title D O AM //�� 2 AM <br /> ®PM lJ J S PM <br /> I2(f0�'o <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(VYhOIe1PTE) e j► ; O O (Fill one only) (Fill all that appy (Fill all that apply) (FII all that apply) <br /> `1 0 Active Q Passenger Q Generator o Outdoor <br /> — D Q Closed �Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR ®End-use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet QGovemment QRetreader 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 •Agriculture Q Shredder O Other <br /> Patt B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityHE <br /> a. a <br /> t y <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§16459 -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§184603-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 /> Q Q Other: § <br /> Comments ] ,,yr,-�_Ir 'b'on S dQct,/and. 1/ -Allow/, J &-10 <br /> 'I <br /> r r On ShLUS jJqAro <br /> •�'I'la 6est� vie hl .fOr .e. s. <br /> rf a 200D v vj"+P S n Bred <br /> t <br /> Inspection Form Included: ZI N235 <br /> Comments Included:Q /(� l <br /> nes fs S nsltlna Phone'Nutdt�. ( Bator' S gesture' Phone Number - <br /> INSTRUCTIONS ON BACK PWE' 11121 <br /> 82081 <br /> ■ White Copy.CNVMB Yellow Copy.Operator Pink Copy:LEA <br /> 0';�29204.0026 <br />