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= g Waste Tire Su ,y & Inspection Report Inspection Report Number <br /> State <br /> CIWMB <br /> f 81(New <br /> Survey Form - Page 1 I 1 - 1141290 <br /> CIWMB 181(New 04/04) <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: l 3 p2 j Q ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � � /tel If Referral,choose referral type(Fill one) <br /> Identifier: �1� C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName Inspected By Inspector <br /> (3ob5 P> rs, n / Vt ���r 3 _ C <br /> Physical Address �` Om <br /> !off 6JOJviv <br /> Inspection Date d 5 O l <br /> Zo6 t CC,_ tsd 410' <br /> Time In Time Out <br /> Business Rep Title 0 AM / AM <br /> (� l go PM <br /> - Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply), <br /> pply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ® Auto Repair 0-Trucking Fleet Q Government Q Re reader 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 FacilityMENTTATtJ <br /> �-r - <br /> ' A klAllt ING ANS IV(ANIFEST IEtliltI1IINT�a f <br /> n 11iaifan Q Frxten fo <br /> 77, <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> dud <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C(tltpiifitlde Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> l .. <br /> �lequirecior N�7t�rrS�l"} <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> ' S k2 <br /> Yvc p 'Af <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q lZefefie )C�WCHB i�nforretnettit <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ��_in C4�p�i�nl4`e �•�Nt� 1/�a�ations <br /> O 1 Q — <br /> Other: § <br /> Comments _ _] Pec7b2"5YA On Ck 7A_ <br /> - - -O 1/1b�GvlcJ --- <br /> n <br /> Inspection Form Included: Q UU ��J�--77 <br /> Comments Included- Q —cC��� ----- <br /> _ Busine s Rep's Signature Phone Number Ins r' Signature Phone Number _; <br /> 3 � �ITCC31'Ce 4P .„ 62081 -- <br /> INSTRUCTIONS ON BACKrlr� #� � FTJ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />