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e5 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of CalHomia /� 1'r <br /> CIWMB181(New 04104) Survey Form -_Page 1. 1 2 - 1 0 0 6 1 <br /> Callfomia Integrated Waste Management A Board <br /> Part.A-Survey _ BLUE OR BLACK INK PER <br /> Business Profile Inspection Details. <br /> TPID- - n Type (Fill-in <br /> Site Suffix: O5 3O ' ( Ot ;Routsne ORe-insp action O Referral 0 <br /> Observation. <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 'SaA- qc—M T(ru 11 t5l 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility N AowQ✓' Inspected By Inspector <br /> A- 1 c t (� _ l J� <br /> Physical Address l'1/ I I t� ( it z- <br /> 54 N C)uFF <br /> Lod ; CA 01 � <br /> .a-2 q 0 , Inspection Date Q <br /> � <br /> Time In Time Out <br /> Business Rep Title 0 AM / I O AM <br /> O <br /> 1 � � 5 ®PM '1/ � 5 •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 /> ' f 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> o 0 Inactive 0 Truck <br /> Longitude .- End-Use 0 Container <br /> 0 Planned OTR <br /> Business Type (Fill'all-that apply) 1 _ <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 ®Other IAK& MpWQa/ e "-- <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 +PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements q <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459,2:1-Submittal of Manifest Forms and Tire Trip Logs Within.90 days 1 <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 1.4 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 Generators <br /> 0 0 Other. § 21 <br /> etc . <br /> Comments 0 ` 2 1115 on �s o GU Wt o Mow=Rur <br /> pted � <br /> All -Hrt6 werAfed at fu's A&jlf' V are Ay�orn lawh was+e <br /> fires on armi-ses e-hW 6P iKsaei cel Vas-fe, -fVes stag-Aakfiept Mitre ov- less <br /> i d ".s-& i 0-<Al she, VV e+tevei- 4_ a wa' k Iiees <br /> Inspection Form Included:0 �� �-Jrat'►3 \ ' �� f�ry�r ��(j <br /> Comments Included: - <br /> ess Rep's Signature: Phone Number lnspector .Signa a -Phone Number <br /> INSTRUCTIONS ON BACK _p �1(,� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA . <br /> 0529204.0798 <br />