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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> �. ClWM1tcellfNew Survey Form - Page 1 1 3 - 1 01 3 3 41 <br /> CNVMB 181(New 04104) <br /> Calitornla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile• - Inspection Details <br /> TPID- ( - O Inspection Type (Fill one) <br /> Site Suffix: , 3 Q Routine Q Re-inspection Q Referral Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: -.�o�q(At Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name i' i J ✓ <br /> Inspected By Inspector <br /> Sc,Ad Fr-e-r+a s <br /> r � ►,-. 'mu s <br /> Physical Address 39 - � f <br /> +- ! I Inspection Date / <br /> �' K�fo G� �sZIO <br /> Time In Time Out <br /> Business Rep Title ®AM O AM <br /> zii N1 3 0 o PM O PM <br /> 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) <br /> r r L 10 Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 Q Other <br /> Part 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. ® z " <br /> Q Q PRC§42956-Registration/Decal in Vehicle K r;, sr " -•ti, J <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ' <br /> Q Oa.t <br /> 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 a �f <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities a ` +t <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ; M„ <br /> Q Q Other: § «' <br /> CommentsL mc-CC." 1 r,G, a r"1_4 <br /> _4 Q �9 _- -j'rre �P•r j to r t."__ <br /> -- <br /> G.s%i'44 d S P.o ye_ .cA n 'tea ��,�-b.t.- L'J- n g ssfA h„�rr� <br /> 1p <br /> Inspection Form Included:QISLA* <br /> Comments Included:Q �g6 <br /> s'Signat re Phone_Number Ins ors Signature Phone Number 1 <br /> TTTI� P T �7 l <br /> 62081 <br /> INSTRUCTIONS ON BACK rj� IE <br /> y � � 14 '.1. <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0605204.0520 <br />