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all <br /> L s, Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Btale of Califo181(Nrnla Survey Form Page 1 i 5 1 0 1 3 3 r <br /> CIWMB 181(New 04104) <br /> california Integrated Waste Management Board <br /> Part A-Surve _ __ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> She Suffix: / 3 9 p 8 3 7 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: tJd2 wAl 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> - <br /> S'�c,�,w�r Inspection Date / ! / 2 9 / <br /> Time In Time Out <br /> Business Rep Title l •AM AM <br /> �xl'-fiG ( n 0 PM d 0 PM <br /> r 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)j <br /> f <br /> *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 — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use FacilityENFQl3CI INNT STATUS ''l. <br /> {�I(ANT f UIREII i.1fi5. w <br /> �' J, <br /> `:0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle -— <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m 1 � <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 �r <br /> 0 0 14 CCR§18459.3`Retention of Manifest Forms and Tire Trip Logs for 3 years <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 <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § tg� 3r�' <br /> Comments - l[+ �• GZ/ Geee G / � Lti �cO <br /> 444 worz <br /> Inspection Form Included:<Dh <br /> 'Included: <br /> �R.pW. gn Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIAkl p I L 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />