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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 67 State of California 1 '/�1 t/�� <br /> CIWMB 181 IN-04/84) Survey Form - Page 1 I $ - 1 0 1 0 $ y y <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; 3 S~ S S Q / 0 •Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. Can c/ALl _,lye — O CHP 0 CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name 4 p� Inspected By Inspector <br /> -L�_-ee "e 0,/ d�`o o+� ,r1 HP /l/Wwel-A <br /> Physical Address I <br /> 1/37 <br /> C, <br /> / Inspection Date / ( / / 7 <br /> Jxe,e y, C,� 9f�J <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 inactive 0 Truck <br /> Longitude _ 0 Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader Q 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 O Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer Generator Hauler and End Use Facility <br /> `�i� ��'iR�g:�-^.H,.�• � -�""` � �;,. x-�xr�'=�.. Tom: 'n .Y <br /> 0 O PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. r <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <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 /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <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 - iZ <br /> O O Other. § _ �K <br /> Comments / �0�[c�,1 - <br /> 1 oti c✓ L % 1 !ii"u.��a� <br /> Inspection Form Included:Q W,4-033 <br /> Comments Included:0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK `" � I �( A ikl P: E; Z 3 62081 <br /> ■ 0716504.0049 ® ■ <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA <br />