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Waste Tire Survey & Inspection Report Inspection Report Number . <br /> trr <br /> State of California Survey Form - Page 1 I 1 - 1 01 3 7 5 2 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: oL g lfl 0 �✓ D / Routine Q Re-inspection Q Referral Q Observation <br /> Local \/�+. If Referral,choose referral type(Fill one) <br /> Identifier: �(i Argy Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By inspector <br /> Physical Addres <br /> a loo C 6-1 s YKar, Ed <br /> �j�' �{ Inspection Date O � / I ( / a <br /> _rraC j f ` ' �� 3-7(a <br /> Time In Time Out <br /> Business Rep Title c 0 ®AM AM <br /> Y s c WS,S �'lr t'Wb0 ] V O 0 PM ' D 3 O O PM <br /> r')'1 �c <br /> lona)Status Tire Type Business Role Storage Type. <br /> Tire Count(Whole/PTE) � � <br /> 15 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 r Q Indoor <br /> O Q Inactive Truck 1' <br /> Longitude — Q Planned OTRQ End-Use Q Container <br /> Business Type (Fill all that apply) _ __ fyi <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 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 >�T <br /> L Nam <br /> QQ PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> k r< <br /> Q Q PRC§42956-Registration/Decal in Vehicle " av <br /> t <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 /> s <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 ! N <br /> Q Qa ��Y <br /> 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 s x s Ts iaa t <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Commentsvhjum K �I�aWI fa krJ A. <br /> '�� -�rres and, hates- ► -t MO ?6 's ovide d- �d <br /> IF <br /> (lP� I►vea & Gre, S ylfiud Aj ik"mnlir P tam lvced e S oPs <br /> Is not �,r� - Gtt 1k r -M' s v tlfn it i nvoi us rvvi'dtd <br /> ot <br /> Inspection Form Included:Q ,yt ��0$� <br /> Comments Included:Q /�j, n <br /> Business Rep's Signature Phone Number itfspba6es ' nature Phone Number' <br /> INSTRUCTIONS ON BACK JEj)(jAMP L: E 4 '2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> 41 r,15 1 A4. x_1486 <br />