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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey rve Form - Page 1 �J - d 2 <br /> CIWMe 181(New nage y <br /> California Integrated Waste Management Board J <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 3 I Inspection Type (Fill one) <br /> Site Suffix: D V ®Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> / <br /> � A If Referral,choose referral type(Fill one) <br /> Identifier: �" J 0 tqe4Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �-vri C L'Vro 4 Q <br /> Physical Address <br /> C+ q53-2& <br /> L � Inspection Date � � / Cl <br /> J Time In Time Out <br /> Business <br /> Rep Title O AM Q AM <br /> esom /VQSlte O aJis s <br /> r 0 PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) / I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Ib Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type.(Fill all Out apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ®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 x"` <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. a. F <br /> Q Q PRC§42956-Registration/Decal in Vehicle <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 /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§16459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years x a6 <br /> ,ss ' <br /> Q Q 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 ` <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q ,.. .. <br /> Other: § -.�.. <br /> Comments R.,i•.__ �,�. /J�S ! _,.1e� Ivt¢ !'D1 not _� , ilf�`,�•,1 i-S <br /> AVC ACV ALC-.ttAA.�WIV Le1A�rC^^;Q -I/ wee 2r40L'- t b ry�z* t. Ar _L '6) U��99 �1.c>LcS-ril <br /> 1�s • �Karia.t'�5"F -r/oyr! � Vi�tuJec� �Df ���y— ���. /VO �i0 ��DnS' <br /> no <br /> twi <br /> c <br /> Inspection Form Included:Q <br /> Comments Included: 7 <br /> Business Rep's Signature Phone Number ector' S gnature Phone Number <br /> ter" 62081 <br /> INSTRUCTIONS ON BACK" / E X AMPLE 1 3 <br /> ■ k ms,p -- S .�� s' - . ;to ® ■ <br /> White Copy:CIWMB Yellow Copy:y OperOperator Pink Copy:LEA <br /> 0708104.0101 <br />