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i Inspection Report Number <br /> Waste Tire Su_ ey & Inspection Repor <br /> 1rn StateCalifornia Survey Form - Page 1 i 8 - 1 0 0 6 3 0 9 <br /> GwMB 181(New 04104) <br /> California Integrated waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: O Routine 0 Re-inspection 0 Referral V Observation <br /> Localn If Referral,choose referral type(Fill one) <br /> Identifier: `\J To emr4 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V Inspected By Inspector <br /> 17'1--ck 'Bros �,r�4 kJ <br /> 3 _ I O <br /> Physical Address E - t'1' `n IpIlne <br /> , <br /> Inspection Date <br /> RID C .fiDri CA- J�20� <br /> Time In Time Out <br /> Business Rep I _ (�_ Title /� O AM O AM <br /> JI' i��'1 VP JCFV O PM O PM <br /> Operational Status Tire Type Business Role ! Storage Type <br /> (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 0 <br /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> o 0Inactive ®Truck <br /> Longitude _ 0 Planned 0 OTR O End-Use 0 Container <br /> Buslness Type (Fill all that apply) I <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ..ENF RCEM NT STATUS__ <br /> V pi; l�ll►k ;ING 1f p M I+IIFEST l k3UIREMIN $ lett n Extension <br /> O - O Notice of 'la ° 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. taolttpljSnFe Ileadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O0 14 CCR§ 16459 -Responsible Entities Complying with Manifesting Requirements <br /> IB Ast9 / m J <br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWM <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days irdt�fprNOVorFXT) <br /> O0 i <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers jEnfamement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators , <br /> 0 0 Other: § <br /> Comments smal-I truck �lee�f .bac il�� des �to vtl;ls�� c�1 tire fv� <br /> ,S2r01Qe, 0,YA afakr r No Was, -e. e.S �� �ruwtcse I�Pov� r�gi�es-� <br /> , aCiLt�y` Pry,dj <br /> hac ��s5- <br /> - i iqk -sc i ssed <br /> Inspection Form Included: 0 J <br /> — -- <br /> Comments lnclrlded: <br /> siness Rep's Signature Phone Number In pector' gnature Phone Number <br /> INSTRUCTIONS ON BACKt7tfEtrf 62081 <br /> White Copy:CIWMB Yellow Copy'Operator Pink Copy:LEA <br />