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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 8tateof 181NCalifornia Survey Form - Page 1 1 6 - Q 1 3 4 2 <br /> CIWMB 181(New 04/04) <br /> Callfarnla Integrated Waste Management Board <br /> Part A-sumy BLUE OR BLACK INK PEN <br /> Business Profile Inspection.Detalls <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: i O 8 0 0 Routine O Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� �p - 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ffw ift Ali ykm e'k+ ary i u s <br /> Physical Address l� 3 - t 0 1 l U ; � Z <br /> gaS- S E( T�r-adc) <br /> S-I „ C�f (�/16-z1� Inspection Date 0 / 21 -7 <br /> / <br /> �4JTime In Time Out <br /> Business <br /> fRep <br /> ^'y� Tittll�e` 0 0 O AM 0 AM <br /> ®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 /> O Active 4j Passenger 0 Generator ®Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> o 0Inactive 0 Truck <br /> Longitude - O End-Use O Container <br /> 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer ®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 O Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 707 PRC§42951-Waste Tire Hauler Registration and Transport of Tiresa <br /> O O <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal In Vehicle '`'' <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 - ' <br /> 14 CCR§18459.2.1-Submlttal 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 <br /> O O <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities ;xT <br /> O O <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 101 O 1 Other. § - <br /> Comments ' 16, )/ WAS s Fac - does <br /> �ww�� !2 otr (OS <br /> 116.1 <br /> Th ke s. FagV,,,'f3j -h reb..in Ig- <br /> o o ea,�.s � "-o✓' r cl"iom , V 10 <br /> Inspection Form Included:0 qD Oq� <br /> Comments Included:0 . <br /> usine 's Agnalure Phone Number ' Inspe4oles loature czPhone Number <br /> INSTRUCTIONS B K I EjXjAjMjPjJ_jEj1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA ® ■ <br /> 0609004.0025 <br />