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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Crate ate 181(Nrnla Survey Form - Page 1 1 3�- 0 3 3 6 6 <br /> CNVMB 181(New 01104) <br /> Cellfarnla 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: f— o Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: r^ <br /> —S '�—. �N�..'i'y CK.� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> 24 oS N EE,P <br /> b S Inspection Date / 6 <br /> onr <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 — O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> D *Active ®Passenger ®Generator ®Outdoor <br /> O I <br /> Latitude Q Closed Q Altered <br /> GI?$ Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> ........... <br /> y£is 'r „k' °,`�<4c3+ <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires - <br /> i <br /> �i <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O Q PRC§42956-Registration/Decal In Vehicle , <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days E f h1 <br /> I a. <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers �• ~ <br /> OO 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *t `✓ _. „. <br /> 7 <br /> O O Other: <br /> Comments t'_/Qv.1'�j75 t,,,Jgs,IL �•.i1,p�S 4�y��i ,a �e.[II�I� �%S�Sc, <br /> w•f�iSd✓w� 7�..¢� a��li�f'•�' <br /> '%�^�I Ori a ! G�c•-.j�G S�+, _ - <br /> Inspection Foran Included:Q <br /> w <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number In s Signature Phone Number <br /> INSTRUCTIONS ON BACK IIEIXIMIPIL9 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 0605204.0539 <br />