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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of Survey Form - Page 1 1 1 - 1 0 1 3 7 5 2 <br /> ClWMB WMB 181 781(Now <br /> 041 4) <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Busi�file Inspection Details <br /> TPID- Q� rInspection Type (Fill one) <br /> Site Suffix: O g p Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name VInspected By Inspector <br /> Physical Addres <br /> a 5 Tao c&r- s ,vta rt- Ed <br /> �raC1 171� 3—ko Inspection Date O 0 l_ <br /> f Time In Time Out <br /> Business <br /> /Rep Title } !, ®AM ®AM <br /> 1 <br /> Y eVr' I'YJ �.�Sf S �Vt �GI�DV1� V O OPM � 0 3 D OPM <br /> tonal Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> Tire Count(Whole/PTE) e15 0 <br /> Active Q Passenger 0 Generator 0 Outdoor <br /> GPS Latitude <br /> O Q Closed Q Altered <br /> 9 r /�-Q Indoor <br /> 0 Q Inactive V Truck 6�Y <br /> Longitude - Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ( Trucking Fleet 0 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. <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 CIWMBM� <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days k 4 zx a s <br /> Q Qr3 � r <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years e ,N <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers � � 1 <br /> 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> t <br /> G <br /> Ti <br /> t <br /> W <br /> l <br /> D <br /> Ti <br /> f <br /> t <br /> i <br /> R <br /> 14 CCR§18462-Manifest System Requirements or re Dealers or ase re Generators <br /> "�t <br /> Q I Q <br /> Q Q Other: § i % �.. <br /> Comments (/U7 u iYIS� �n �5 d -1-4�llow i t�o `5 a <br /> sand, - ► A) <br /> ' lud �p f�.nrfwn lir Anti 1 vCa.{ Are shop s r�(tt/(�t Dh <br /> +S YI.Dt (h( �i�.- nl r_� S V' �m if • r25 ��1/rt�tC�. <br /> Inspection Form Included:Q <br /> Comments Included:0 '�0$� <br /> Business Rep's Signature Phone Number I s ctor's Pfinature Phone Number <br /> ORWIRM <br /> INSTRUCTIONS ON BACK <br /> >' C p L i ;2 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> F1 6 15 10 4,l_1 4:-_:E. <br />