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Waste Tire Sul vey & Inspection Repor . Inspection Report Number <br /> State CIWMB <br /> 181(CalifoNew <br /> Survey Form - Page # 9 - 0 Q 8 3 8 <br /> CIWMB 181{New 04104) <br /> California integrated Waste Management Board <br /> PartA- Suryey BLUE OR BLACK INK PEN <br /> Business Profile -- - Inspection Details <br /> TPID- �. - Inspection Type (Fill one) <br /> Site Suffix: 5 ' Routine Re-inspection Referral <br /> ® Q p Q 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sala—J'owo, V1 OV�Ln�h 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (� - - - - -- <br /> v inspected By Inspector <br /> S Q5 <br /> Physical Address 3 <br /> Y <br /> l 6oaq Ay-j jjY &, - <br /> C 57.2v Inspection Date <br /> J J <br /> Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> S N 1 t��t� Tt�ccnS !V t/ O PM � PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) h (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that app)y): <br /> 0 Active Q Passenger 0 Generator 0 Outdoor <br /> 0 Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0Inactive Q Truck <br /> Longitude - 0 Planned Q OTR o End-Use 0 Container <br /> Business Type (Fill aii 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 r <br /> 0 Service Station O Hauler 0 Agriculture 0 Shredder (� Other is v i 101,1 {p� �2vt ✓` <br /> I <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> ,. ,. . --_.-._:..::.... .. <br /> IA10. "df! ! 'ri!�l�R v <br /> ,s.. - <br /> PRC 42951 -Waste Tire Hauler Registration and Transport of Tires r•< % •./ - jam .. <br /> o yo g p /� <br /> O O § Registration/Decal <br /> l / <br /> PRC 42953-Contracts with Registered Waste Tire Haulers, // <br /> PRC 4295fi-Re istration/Recagin Vehicle <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 /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 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 / <br /> 0 0 <br /> 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 ' y <br /> O 1 O :Other: § r ; <br /> Comments <br /> - Ra c� {` �_ t1va-S .s doe c t_-e 4 , s C-'C a <br /> 'f?�eaG��. 'Vied r7e eeewt _ I'll t/o�C�, as . 1 n ver C e.S al` dor o,-z ;f d zGeS I' <br /> Q�J r tC'rlr . - W.► l ri?' IK Ca .�S of' V�Iaf'(.t S S onS17� ►- S ` ✓5+ <br /> Inspection Form Included: 0. 15w- <br /> Comments Included:QNL 4-1. - <br /> �_ sines ep' Ignature Phone Number Ins ctor's nature _ Phone Number <br /> rr i✓ ii�,riN'!� y i 62081 <br /> INSTRUCTIONS ON BACK � �, / �- ; . a ?/i�I P L E12 3 <br /> . <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />