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Waste Tire Survey & Inspection Report Inspection Report Number <br /> state of Callfomia <br /> CIWMB 181(New 0 Survey Form - Page 1 1 9 1 0 2 5 7 3 9 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ _ __- -_ BLUE OR BLACK INK PEN <br /> Business Profile _ _ _ Inspection Details _ - <br /> TPiD- t Inspection Type (Fill one) <br /> Site Suffix: ` 3 '5 In 7 6 \ • Routine O Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> in2spected By Inspector <br /> Physical Address <br /> 6 c)-2 . I-., ,,La,w.at yr <br /> "J—A— CIA <br /> v^ A 5�Ll_-i."0 inspection Date <br /> L ` / Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> O PM Q PM I <br /> - — - Operational Status Tire Type Business Role Storage Type 1. <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply). (Fill all that apply) (Fill all that apply) <br /> f f <br /> ®Active Passenger Generator Outdoor <br /> O O Closed O Altered <br /> GPS Latitude 0 Hauler O Indoor <br /> p Q Enactive *Truck <br /> Longitude _ ' {� OTR — O End-Use Q Container <br /> O Planned <br /> Business Type (Fill all that apply) J l <br /> Q New Tire Dealer ®Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body 8 Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility +?�j���� <br /> M>"N"F� ; .. ` . •:, - � ��� ��'" �����".�,,,, <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires �i ;'%/✓� ',/ ' <br /> O O <br /> PRC 42953-Contracts with Re istered Waste Tire Haulers. �y,�� ' .%✓•/��� /� <br /> MIR M <br /> PRC§42956-Regis iratlonlDecal in Vehicle <br /> O O 14 CCR§1 B459 -Responsible Entities Complying with Manifesting Requirementsj ,, <br /> O O <br /> 14 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 <br /> i <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O 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 /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § � <br /> k , <br /> Comments ^�1' t••-ty�,y,s Go>�e� .- r_ 11As �_ Vett . <br /> �P, D <br /> 1 _ t3 -50-76_- bl _ lam - Cl�✓,vl�-}a , s�, �- _ <br /> Inspection Form Included: Q <br /> Comments lncfuded: Q - g — - 76 M <br /> Bne Rep' Sigre Phone Number In _ Phone Number I <br /> iVW'i. 62081 <br /> INSTRUCTIONS ON BACK 1 �.1 f I:;X A N P L fy I Z1,3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />