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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California Survey Form -..Page 1 1 1 . 10 6 6 6 G o <br /> CIWMB 187(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR.BLACK INK PEN <br /> Business Profile. Inspection Details <br /> TPID- 0 Inspection Type (Fill one) <br /> Site Suffix: a $ I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local (� /� 1 If Referral,choose referral type(Fill one) <br /> Identifier: ,SQ�n S��� l U,••T• O CHP O CIWMB Q Complaint .0 Educational Visit 0 Other <br /> Business or Facility.Name �'-w jr�� <br /> Inspected BY Inspector. <br /> w,2s-+ coc s� Cbvi� <br /> Physical Address 3 9 - O 'I ITjs,"; Pw Z <br /> Inspection Date D 9 / 0 g / () S- <br /> Time In Time Out <br /> Business Rep Title ? (SAM r ®AM <br /> C�!-i,�.�.Lk <br /> r O �^ 0 PM I ' pl O Q PM <br /> S t d rPi t�`�f-i dans r. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) O (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 /> GPS Latitude D 0 Closed 0 Aheredb IndoorjlA <br /> O <br /> Hauler <br /> 0 0 Inactive ®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 ®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 — eQyy) Td r/fin ►F <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility A ; <br /> k.. .. <A: } ' f '} 4• i <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. a .�.* <br /> 0 0 PRC§42956-Registration/Decal in Vehicle &<• r " <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB $ <br /> �4 <br /> 0 _0 14 CCR§18459.2.1-.Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years , t Y <br /> 0 0 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: § <br /> Comments Rokiimiv44 � -A daw ajui A&,, fol-iowiim wo-s Vl.of!d <br /> 64eZ11--v iS u5iL,1A C llSiFoFOr4A iire S4aryie-es, in d0 ices <br /> �e Ld wpon ncg t e.sjqee-t A,-,.s 17 cQrne^f- +r"t*:-S . No fire s sfw,!4 64 <br /> Fael4y on `ti 4 t apga r laces 3 +ir r -3 WM Ott s- A/o Vloia "o <br /> Inspection Form Included:0 <. <br /> SCus re per . <br /> Comments Included:0� ��� � � 170 3— _ - <br /> Business Re Signature Phone Number insp rs Shdature Phone Number' <br /> INSTRUCTIONS ON BACK <br /> �rie#s Tt1� �fi1 62081 <br /> MPLj 1 � 3 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA <br /> 0_72q204.0779 F_1779 <br />