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=z , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> I State of MB18lifornia Survey Form - Page 1 1 1 - 1 0 31 $ 2 <br /> CIWMB 181(New 04/04) <br /> Callfomla Integrated Waste Management Board <br /> Part A-SurVe BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details . <br /> TPID- / n � - / Inspection Type (Fill one) <br /> Site Suffix: / oG 16 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local //77� 111 If Referral,choose referral type(Fill one) <br /> Identifier: VjQL��Gc.i C�c�.v 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date 0 T' / to 2 07 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> r-—� O PM O PM <br /> C/ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> ,,,[ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (/j! <br /> f ' 0 Active 0 Passenger •Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude _ 0 Planned 0 OTR 0 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 0 Agriculture 0 Shredder io Other f���yrCa <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ��NF0 C_M"ENT STATUS <br /> 1�m�ili ME <br /> MAN <br /> r d Notice C1t Violation, (DExtensson <br /> 0 0 PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance'Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements gateEI <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB _j <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days } <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 Haulersa# rd(Cz1Xy _ rtfet4ler## ' <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 10 1 Other: § <br /> Comments �"a�t" G�or� IiLO'J� rip GJ' lti, clic <br /> Inspection Form Included: 0 <br /> Comments Included: 0 ` '3 A4"l � DS <br /> sin Rep's. Signat a Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK - 0 1 P �L i 1 2� <br /> 1 r._i 41 4, 4_141'1 White Copy:CIWMB Yellow Copy.Operator Pink Copy;LEA ■ <br />