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Lf, Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> �f <br /> State of Survey Form - Page 1 1 8 - 1 0 1 3 0 0 8 <br /> CIWMB 181(New 041041 <br /> CaNfornla Integrated Waste Management Board <br /> Part.A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspactlon Detalts <br /> TPID- /; (; t� - O I Inspection Type (Fill one) <br /> Site suffix: `T f I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier C 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected BY Inspector <br /> (dti/i oLck is <br /> tY�_ _ <br /> Physical Address) (�( GY - r 0 <br /> 71/6, c �tit�� �,�ay - C.►w�l fffv�"^ rr <br /> C vl-51)GS Inspection Date /� / I g / 0 160 <br /> Time In v Time Out v� <br /> Business Rep Title 0 AM 0 AM <br /> QPM 0 P <br /> Operational Status Tire Type - Business Role Storage Type <br /> Tire Count(Whole/PTE) ;2 C) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V ®Active Passenger 0 Generator ®Outdoor <br /> GPS Latitude O 0 Closed 0 Altered <br /> 0 Hauler 0 indoor <br /> 0 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 Deafer 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 Insp�ejc�tioonofyWaste <br /> yTire <br /> gDealer,Generator,Hauler and End-Use Facility NFQFtCEAht fdT�TATt)S"r <br /> Y -•� f�a�J�,IPIl7rAN 111At`/A3:471 75 �t�iIf1E 1�7 -, -- <br /> Notice Of Vaoltatian Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Regi,,r,itioi and Tanspuit of tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deudiirie . <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 /> Y <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 <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 K 9 <br /> 0 1 0 1 Other.. § <br /> Comments v�-I4►I� 1 C,{Zern �`'td,J + 16 1;flwos hD-',,Li; wel/ " <br /> Us elegy fifs !ib ted tti"'t2 fixes mow. , L i �eWM I a eye ct <br /> gonna c aF USIA -hc.s u.'Lfh�K io'. o_ lh OIL SIC Ri e <br /> - - + V,-WeA . )11) J"'o�c0. i s . <br /> Inspection Form 1ncluded:0 9 _3_g01q - <br /> Comments Included:0rC_&4_s <br /> / 7N r _na re Phone Number ns actor s J nature Phone Number <br /> INSTRUCTIONS ON BACK AA P E1. 1112131 <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 052.6304.0294 <br />