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==r, Waste Tire Survey & Inspection Report Inspection Report Number <br /> r� StateCaliforniawSurvey Form - Page 1 1 9 1 01 3 1 4 9 <br /> CIWMB 181(New 641041 <br /> Callfomla Integrated ed WastesteManagement 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: Y _ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local n f If Referral,choose referral type(Fill one) <br /> Identifier: S p/ �r 0 CHP 0 CIWMB <br /> 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name — <br /> �— Inspected By Inspector <br /> Physical Address — <br /> 3 9 / � / «e,s-dam�•.-� <br /> �3a3 �lrory4r lf/ -- - <br /> Inspection Date r% 7 / 2 / -07 <br /> �i�gel� �r9 Q S'a-oG <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) _—O " (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)! <br /> r ®Active 9 Passenger •Generator 0 Outdoor <br /> GPS Latitude O 0 Closed 0 Altered <br /> Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 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 Dealer 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-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> �`y~'a" g <br /> III <br /> 0' 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires r .. <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle g' x <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB "n <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years »l 1 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ry <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 Generatorsji <br /> 0 0 Other: § ` <br /> CommentsCf <br /> , <br /> `P.i /gtdt!'C�Q J %fit ql /'�c�ore td / �7L S v, ec✓ <br /> re 5� tri <br /> Inspection Form Included:0 pG n <br /> Comments Included:0 a�& 44/_3 3_ ? �i�B�/1 !01 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK 162081 <br /> E I?C A I,M P .� ! E 1,:2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 0723504.0178 <br />