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ECE <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StWMB California Survey Form - Page 1 1 1 1 0 1 3 4 0 6 <br /> CIWMB 181(New 04104) <br /> Callfornla Integrated Waste Management Board RECEIVED Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- R - 0 ( Inspection T I <br /> Site <br /> Site Suffix: ®Routine Q Re-Inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S�Yl, 0 () n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Ot t �s �er West #X35 3 9 - ! C) 1 J-F.K-�- �Z- <br /> Physical Address <br /> to w. C� tiwy -- <br /> Inspection Date l Z / Q 7 O <br /> StaG1�tD✓t C� ����(n <br /> Time In Time Out <br /> Business Rep Title Q / O <br /> 0 � y ,� 0 PM <br /> 41ALa Loccthcw" Yjr -u--I o Pti, - - <br /> Operational Status The 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 /> ' ° ®Active Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered 11 <br /> GPS Latitude Q Hauler Q Indoor 'v <br /> O Q inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> i <br /> Business Type (Fill all that appy) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire <br /> rD <br /> r <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 4"yft\p-j lo ' <br /> Part <br /> B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <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 � <br /> 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 7 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators a <br /> Q 1 Q 1 Other: § `` <br /> Comments f ✓� fJ�1 Q U"i 121 <br /> 4nLLIWS'. No Wase 4./ oA e. c/eS Seiru'— Q i(SDn W cii-- <br /> hrot nn ii W ','bufgd -Kre..P ��, vL©1alio <br /> Inspection Form Included:Q <br /> Comments included:Q <br /> B sliresioiffelp nature Phone Number in or's ure Phone Number <br /> INSTRUCTIONS ON BACK A P 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 1711 A i t_i 4,ki"2r <br />