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u , Waste Tire Survey & Inspection Report Inspection Report Number <br /> BCalifornia Survey Form - Page 1 1 7 . 1 Q 1 3 7 3 <br /> CMRNMB MB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> S O 7. - <br /> 0 Routine Q Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: QCHP QCIWMB QComplaint Q Educational Visit Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> f1 1t14-,?_ Narfrneri c� <br /> Physical Address 3 9 - _10 &t15 <br /> 14, <br /> -toCt_t n/ ^ 520 Inspection Date 0 -3 / / O <br /> J !lJflr Time In Time Out <br /> Business Rep,�./ ^Tit e n 0 AM Q AM <br /> IrbQ r hJiy on O (I,J! ; <br /> PM QPM <br /> - — �m Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ,s Generator 00utdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude _ 0 Planned IS OTR0 End-Use 0 Container <br /> Business Type (Fill all that apply) Vt <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 ®Other Maphhurl <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility - <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. p: <br /> 0 0 PRC§42956-Registration/Decal in Vehicle . <br /> a <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 /> 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 = r F <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 1 0 1 Other: § f <br /> Comments A u.�ien 1 "S . 1 n `, r eS ck— <br /> ` �S�'"�o�m5 r_l r_ZIA <br /> I a Ad �z1''eS jr S ti Si:�e � &f o✓e-�-1 e To av ` on r uas+ire ro <br /> I,gnd utG dtwiago(t dL<4u <br /> Inspection Form Included:Q �CJa <br /> Comments Included:0' - *ign.�tur.C__ <br /> qL�LI!B nessReps Phone Number I s actor ignature Phone.Number <br /> INSTRUCTIONS ON BACK E'X A,M P j E 1!2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 15 1 F_i 4.0 7 16 <br />