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u Waste Tire Survey & Inspection Report Inspection Report Number . <br /> State e181(Nmla Survey Form - Page 1 1 4 . 1 X 1 3 6 $ 9 <br /> Millie <br /> :IW taidW (New nag i <br /> CalNomla Mtsgrated Waste Management Board <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: pC y y 9 - / ;♦Routine O Re-inspection Q Referral Q Observation <br /> Local / n" If Referral,choose referral type(Fin one) <br /> Identifier: O/Oate"-;j (Z f1+�,r��— O CHP —Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ^ Inspected By Inspector <br /> Physical Address �,G40, 46.,'9 <br /> 93x07 Inspection Date 1 D 0 2 0 6 <br /> Time In Time Out <br /> Business,JRep Title f 42 /1 v 0 AM n _ Q 0 AM <br /> (/ <br /> _ (i' 7 9 PM � C J 7 O PM <br /> i Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 0 ,0 <br /> D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r r 0 Active 0 Passenger 9 Generator 0 Outdoor <br /> O O Closed Q Altered <br /> Latitude <br /> GPS O Hauler Q Indoor <br /> O O Inactive 0 Truck <br /> Longitude - Q Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer O Auto Repair O Trucking Fleet Q Government O Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station O Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityHNFa3RGf MENT$T6TUti'' <br /> �_r._. <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of violation QPxtension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. 9'.040ce,i7lipe , <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements Date <br /> Q O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB . . <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs Within 90 days (fdagtralbrMfTVznkT <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years 3 <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O Q Other: § <br /> Comments f e �r 1 d a4-e <br /> -- /11' <br /> is W glp /ucc a rt k/Q c PS/� <br /> vtt%tcve r� dao r �r/ ,mac K rt pa" &,�e <br /> Inspection Form Included:Q /�""►'"-,Y /�I, ��'� wComments Included: <br /> usi Rep's gnature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTION ON BACKX 14 iM P L E 1117-131 62081 <br /> ■ Whin Copy.CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br /> 0629804.0345 <br />