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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Steleof B181 fornla Survey Form - Page 1 I - 4 1 3 4 8 <br /> CIWMB 181 stew 04/041 <br /> California Integrated Waste Management Board <br /> Part A-Sulve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ^ Inspection Type (Fill one) <br /> Site Suffix: I a 5 d © ®Routine Q Re-inspection Q Referral Q Observation <br /> Localcam`� � l — If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Q T;r2s <br /> Physical Address 3 – ' �eyt - �1AaZ <br /> Qq o O-e4ra1 Ave <br /> Tna C CA- g 5 3 7(a Inspection Date 2 C) / b S- <br /> Time In Time <br /> Business Rep Title O AM Q AM <br /> .J lJ PM (> JZ I ® PM <br /> - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W holelPTE) r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O <br /> ' ' 1 ®Active ®Passenger ®Generator if Outdoor <br /> O Q Closed Q Altered <br /> GPS LatitudeQ 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 /> i <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 <br /> Q Q PRC U.N. -Waste Tire Hauler Registration and Transport of Tires t ze a t <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 , <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments n pk1" W 1'lp7�C e <br /> Sil evv *9,5 rAd u. EDT-J WK vi oar <br /> rc o 'ss - 1,q 'oKs. Wa,�&__ -tires wmm.PK <br /> WP/1,a414- G�tS'�Yi vt 1 ,nf, r <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> A(neAs ep's Signature Phone Number In"AIM <br /> nature - Phone Number <br /> INSTRUCTIONS ON BACK L E I Z 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0601904.0050 <br />