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[97 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 1 9 - 1 0 1 3 1 8 1 <br /> California Integrafed Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection/ r - ` Inspection Type (Fill one) <br /> Site Suffix: f *Routine Q Re-inspection Q Referral Q Observation <br /> Local �__� H Referral,choose referral type(Fill one) <br /> Identifier. CGiY�. �lJCc.:Gri��'7 (SFJ' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name C _� -- <br /> /7 Inspected By Inspector <br /> (lC!74t"'-� `c2��L LZ' <br /> Physical Address / - S�G"A'a ii/'y'PW <br /> SC�G � %SD6 Inspection Date (�� / / f) 7 <br /> 4 Time In Time Out <br /> Business Rep Title O AM O AM <br /> a� /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) / -'(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' !Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 07 <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires £ `3 y <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q 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 a <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years r <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulerstsaf�� <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities ri 1 �x <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 10 1 Other: § <br /> Comments yu, .. d-Jix tpyaf t��iy a2e�el� T !s/'�f <br /> Aze.,'e, <br /> Inspection Form Included:Q <br /> Comments Included: 'lid .2 <br /> Q <br /> _ B ossa Rep's Signat re Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK pr 62081 <br /> ■ White Copy CIWM© Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0710204.0203 <br />