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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of <br /> ClWM Survey Form - Page 1 12 - 10137 /29 <br /> CMIMB 181(New 04)04) <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- I n ' _ Inspection Type (FIII one) <br /> Site Suffix: 5 Routine Re-inspection® Q p Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. ` yl joa li,L'y� C Q CHP Q CIWMB Q Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ./j1 a. vmct -Proa/ucfs 3 q - t C <br /> Physical Address <br /> C Inspection Date <br /> CJ � � �` 3� Time In C) 'G <br /> Time OutC <br /> Business Rep Title �.' Q AM O AM <br /> '-2 '3—L��� ��(iC{✓LGA—� p G1�1'�.V� ® � a PM D v : l �� 0 PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> e r <br /> Active Q Passenger i 0 Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude _ Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair i 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 Re <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ' <br /> 11401 <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires x, <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. ' <br /> O O PRC§42956-Registration/Decal in Vehicles <br /> c-� r <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 14 CCR§18459.1 a b c -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days :. r <br /> 14 CCR 18459.3-Retention of Manifest Forms and Tire Tri Logs for 3 ears <br /> O O § p 9 Y <br /> O O ± . . <br /> 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 a^ <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O OOther. § Hca 4 <br /> —1 <br /> Comments .-�.aki'Lt G �e f k,-S nol ; !�'G� iilrtlltl C— <br /> 46s okA rwOdes wood( 'Pq/ S 011e -fraCf&- /S <br /> ►,v>7 cgs V;gW, . Waste 1 i✓� <br /> qitd ob,gaRd. Ab Viril <br /> Inspection Fonn Included: <br /> ',!�6� �f,Comments Included:Q ,m o;?,45 Z� fa v <br /> Business Rep's Signature _ Phone Number recto s'Slgnature I Phone Number <br /> _ R j � 62081 <br /> ■ INSTRUCTIONS ON BACK E X a M P L 1 2 3 <br /> , s YY ,' © . <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br /> 0-.15104.0743 <br />