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_ 091.82040394 <br />==Waste Tire Survey & Inspection Report. . Inspection Report Number <br />HIM _ <br />tl State of CalRomla <br />CIWMB 181 (New Cued) <br />Californiaurvey Form - Page 1 FII 1088486'___j California Integrated Waste Management Board <br />Part A - Survev BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - <br />Site Suffix: <br />—�—u—, <br />Q <br />Ilodl <br />Inspection Type (Fill one) <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />®Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) - <br />Q CHP p CIWMB p Complaint Q Educational Visit p Other <br />Local( r II <br />Identifier: Sao J a LGI f1 1 11 <br />6 <br />Business or Facillity <br />pN,ame <br />Leb„\ S- cA-S VL v I1 <br />Inspected By Inspector <br />Physical Address <br />_ <br />LL <br />L36_—�S_A_ U rM�_4VA— _j <br />Q <br />O <br />Strew_ G_ A <br />r� <br />� Ins ction Date <br />_ <br />Icily - Stats Lf?� ods <br />Business Rep Title <br />Time In Time Out _ <br />' I - 0 AM Q AM <br />l <br />�J <br />Q PM J <br />J PMfIN <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />' <br />1 Q <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that appy) <br />(Fill all that apply) <br />(Fill all that apply) <br />f <br />40 Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />Generator <br />Q Hauler <br />Q Outdoor <br />Indoor <br />O <br />GPS Latitude <br />Q Inactive <br />0 Truck <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />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 Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder ® Other S_6t 1 i fe -j <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />1 Q <br />1 Other: <br />Comments /1. L 1 <br />1 CC— <br />inspection Form Included: U ' <br />Comments Included: Q —- �� ? <br />Business Rep's SI tura Phone Number Inspectifs Signature <br />INSTRUCTIONS ON BACK Co r c. correct:M jEjXjAjMjP1L1E11 2g <br />■ White Copy. IWMB � Yellow Copy. Operator Pink Copy. LEA <br />62081 <br />