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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stale of California /� <br /> CIWMB 181(New 04104) Survey Form - Page 1 1 3 . 10 2 5 6 8 3 <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: !. V 7�J 3 3 r f O 14D Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. may( CI ! ' O CHP Q CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> 6 ocd- l Tf res a kid Wheels 22 <br /> Physical Address 3 9 <br /> 3,�s 3 , C e44:-ej <t <br /> k C i-- �0 C4 C) Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM f 1 O AM <br /> / 5 a PM O PM <br /> Operational Status. Tire.Type Business Role Storage Type <br /> Tire Count(Whole/PTE) D (Fill one only) (Fill all that apply) (Fill all that apply)I (Fillall that apply) <br /> r r ®Active 0 Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O O Inactive 0 Truck <br /> Longitude - O Planned O OTR ®End-Use O Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture O Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility <br /> ;. <br /> p Y ti;,off <br /> O .O PRC§42951-Waste Tire Hauler Registration and Transport of Tires Y a <br /> O O . 3 <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O Oa" z... .z.. <br /> PRC§42956-Registration/Decal in Vehicle `�`''�'"�•�` '"=°'"'��`'�''' � + 't`"' , <br /> O O 14 CCR§18459 -Responsible Entities Complying with.Manifesting Requirements s' r <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB ' <br /> O O 14 CCR§18459.2:1-Submittal of Manifest Forms and Tire Trip Logs within 90 days : <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years `F <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ; <br /> O ® 14 CCR.§18461-Manifest System Requirements for Waste Tire End-Use Facilities ` <br /> (:j0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § ti <br /> Comments 1C OIn f Lit 2 I iA SneGf7,t)vt"�,S Aw'+;tA 44+.,e_ h l l Qwl"W Q s ny fcd: KB <br /> FaGlit� uses reai5'+>erec� wa�fc -h�� aulc� ML'T72 1D ✓en�Lo✓� u s�� <br /> -Hres. Nmw CL n ManF sf-A L <br /> 20r•}t✓ 'i I%e- rr 4?,E s Ar !n S ecfi o'e, <br /> Inspection FormIncluded:0 ? 2t )�1 <br /> Comments Included:® " ' �i " "'� -- - 47�vl—,f 4 a - — <br /> Business Rep's Signature Phone Number In ctpr's S a ure Phone Number' <br /> — INSTRUCTIONS ON BACK E . A j P'[ E I 1 ; 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ®: ■ <br />