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Fea. Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> State of California <br /> Lim CIWMB 181(Now 04104) <br /> SurveyForm - Pagel, - 7 - ...006605- <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details > - _ - _ I <br /> TPID- Q Inspection Type (Fill one) <br /> Site Suffix: l 3 7� �Q .m) 3 © 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Sim 3-044 , 1 �� 0 CHP 0 CIWMB Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> ��es PI1 jS"a, bey <br /> Physical Address �� - �� �- �t1 { �Lt-(7i <br /> ���3 Inspection Date 6 / V •� <br /> 2-sc�a yl C�� 10 <br /> Time In Time Out <br /> Business Rep Title / ®AM j 4 ®AM <br /> J O O PM I 1 © O PM <br /> — - Operational Status .-Tire.Type Business Role Storage Type <br /> The Count (Whole/PTE) (Fill one only) (Fill all.that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O ' C Closed Q Altered . <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive .0 Truck <br /> Longitude - 0 Planned 0 OTR End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 ®Agriculture 0 Shredder C Other <br /> . ..,F�•n�r �»:ru F <br /> Part B-Inspection of Waste Tire Dealer;Generator, Hauler and End Use Facility �� <br /> 0 0' PRC§42951.-Waste Tire Hauler Registration and Transport of Tires -0• ' y ,- <br /> 0 0 PRC§42953,Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle ' <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB _ .. .., <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days ` <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years K � <br /> 0 0 14 CCR§18460,2:Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 <br /> 14 CCR§18462--Manifest System.Requirements for Tire.Dealers or W aste Tire Generators <br /> 0 0 Other: § <br /> Comments `Q�,•-i✓1Spex 1Au 1 ki 5 A" Iy- acts Vlot- ed i -- <br /> A I jx uiauS Viata f ovl5 ha-V2 6eeii Lorrz�,ecl . Ac-five dixi 'N kGLS <br /> Wasft. P2moVd 10co 0 roduct <br /> ' 'S o�J . E6iered <br /> KB <br /> Inspection Form Included: 0 e �� M�N <br /> i Comments Included: 0-Business Rep's:Signature Phone Number I actor ignature.; ber <br /> yK .r r 62081 <br /> INSTRUCTIONS ON BACK e c lfre�€, .0 �� i X[AIMI ,L E . 1 z 3 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 0529204.0831 <br />