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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Jf <br /> ClWMa 181(New 1""" Survey Form - Page 1 1 1 - 10 10 7 0 9 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection/ Inspection Type (Fill one) <br /> Site Suffix: d ®Routine QRe-inspection QReferral <br /> Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: C� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �'/// Inspected By Inspector <br /> .�wr�iC�z �0�D -S / <br /> Physical Address <br /> S1�6` y � /C }5705 Inspection Date <br /> 'oY`/-li-Vn if( -r %TT� Time In Time Out <br /> Business Rep ��(I e,( S�l4LU0t/u f ilia �'l S'tal(Q:� O AM O AM <br /> V 1�* r CNuAS ©WKLY O PM O PM <br /> �Dirati <br /> nalStatus TireType BusinessRole Storage Type <br /> Tire Count(Whole/PTE) one only) (Fill all that apply) (Fill all that apply) (FIII all that apply) <br /> ' / ®Active ®Passenger ®Generator IA Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q 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 pjj <br /> Q` Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires � r hsy r <br /> Q Q !PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O Q PRC§42956-Registration/Decal in Vehicle u <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 <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q �. 4 a <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities F "? ' ��•�t,ry.� - <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste The Generators :n..-�•�,� �� +`%"` i' <br /> O Q Other. § <br /> Comments-leftL ` / I i01�S Was <br /> o di,l ' l r ujule -ire s 4 VA <br /> ne r ` cbr fs _,real Mqi� fiesy-s._ <br /> W1 r I w- revieW or *'Td wi Ms-e 4Lf <br /> Inspection Form Included:Q <br /> Comments Included:Q - .'^ <br /> soaks Re 's Signature Phone Number Inspect r Sign re Phone Number <br /> 62081 <br /> ■ INSTRUCTIONS ON BACK FETX51MIPILIN I13 <br /> 0716504.0043 .:Opera ® ■ <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA <br />