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Waste Tire Survey & Inspection Report Inspection Report Number <br /> C11Mr181(NCalifornia Survey Form - Page 1 7 - Q 1 0 6 <br /> CIWMB 181(New 04/04) <br /> CalHomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 7 O� Inspection Type (Fill one) <br /> Site Suffix: ' 3 CJ ®Routine Q Re-inspection Q Referral Q Observation <br /> Local Y� H Referral,choose referral type(Fill one) <br /> Identifier: (/,��h � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ]`� <br /> Inspected By Inspector <br /> pbaFc- S-fvv-ar� 2 . P <br /> Physical Address •� <br /> 620-7 - 13 lu. car l ton Ae <br /> S I IN/ ' rq G4 9-5p-03 <br /> - Inspection Date <br /> Time In + ` Time Out <br /> Business <br /> �Rep <br /> n,-�l Title �A O AM O AM <br /> O PM O Pk-1 <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ®Active Q Passenger %Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0Indoor�/��7/ <br /> O Q Inactive i ®Truck <br /> Longitude — -- — — Q PlannedA OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other 9Vraqe f dn4 <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFOEEMElti11`AiUS '` <br /> 'iJ10 MAM 5 12EQ(lIFiEM NTS <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> � § 9 Compliance Deadlias <br /> Q 0 PRC§42956-Registration/Decal in Vehicle m m <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB I J <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requved for NOV or_EXT� <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 Referred)CIWMB k '; <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 Generators10 to Compliance - Na Vtolattont <br /> Q Q Other: <br /> Comments f�,,,,-/;t e �1 -�'/,�GlLa e �_�-)1 W FOP o`wW, �k)al s r�l�aff ed FO),kk St <br /> +ti cL _ lS.lrt'slL�� M(VdA J` w ll� V J&i. 1 V t_S . t�-dJ/ 5 vra tJdr r1 <br /> ir�S S: r .gin. . �J o JI a zt�n S �� <br /> - - <br /> Inspection Form Included:Q r <br /> Comments Included:Q _�ejtl <br /> '1W'Y9 <br /> 66 <br /> Business Rep's Signatur Phone Number spe for s SI n lure Ir J Phone Number <br /> ■ INSTRUCTIONS ON BACK 62081 <br /> White Copy CIWMB Yellow Copy Operator .. Pink Copy.LEA ® ■ <br /> 0634704.0264 <br />