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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> er <br /> CMANS 181(NoCalifornia 4 Survey Form - Page 1 1 3 - 10 1 3 0 0 3 <br /> CIWMB tet(New 04M41 <br /> callfomis Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection O Inspection Type (Fill one) <br /> Site Suffix: If 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: Sao, JQa &LOfM "1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> t I <br /> Business or Facility Name - - - <br /> Inspected By Inspector <br /> Lice- W LiS�►�anflors 3 g _ 1 o I J' �t.� <br /> Physical Address <br /> 930 1Q y <br /> S '�Vn C4 C15 UP Inspection Date O 8 / � 0 / 0 Co <br /> J Time In v Time Out <br /> Business Rep Title J O AM O AM <br /> ✓I l �,ll Q C C7 6YvkWl� O PM O PM <br /> Operational Status Tire Type Business Role Storage Type. <br /> Tire Count(Whole/PTE) !^ 0 (Fin one only) (Fill all that apply) (Fill all that apply) (Fill all that apply). <br /> f u! 0 Active it Passenger to Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - — Q Planned Q OTR Q End-use I Q Container <br /> Business Type (Fill all that apply) <br /> Q Newlire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 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 CEt�IE <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice Of Violation (�Extenston <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadluile <br /> Q Q PRC§42956-Registration/Decal in Vehicle --.- <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> nat <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§16459.3-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 /> Q Q Other: § <br /> Comments Pokfekck5i�eC /W►'tAks ,,, was mhe <br /> rr J r / <br /> circ �y has riot (946 ecP cr�� ��-p&es ivy ks' - u ett , Owt�ier5�ty� is C�iar <br /> and -f11t _ arri vas GGSfis_Sbc'(Jf. Verd has 7'Vn Cla"S and Is--.lh � <br /> QG CA" • 50wic -hre s _Maj be uslu( iV1 r " • eat-S, A10 V,,0 �94•S <br /> Inspection Form Included:Q }� <br /> Comments Included:Q_ � VCKAn1C!�yriV ` . O <br /> Bus ass Rep's SignbbKure Phone Number actor a I nature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI 111213162081 <br /> ■ While Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0627704.0060 <br />