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=s , Waste Tire Survey & Inspection Report Inspection Report Number <br /> State C1WMB 81(No la Survey Form - Page 1 1 3 10 13 6 2 2 <br /> CNVM8181(New 04104) <br /> CaOfomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / _ D / Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C7 / /7 If Referral,choose referral type(Fill one) <br /> Identifier: J LLIL �/D /� (,t7ccy: — 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Busin ss or Facility Name – — <br /> � Inspected By Inspector <br /> :';Y Z­,X <br /> Physical Address <br /> 577�� A S`�D/ Inspection Date 6 6 <br /> (� y C� Time In Time Out <br /> Business Rep Title � � � / � Z� Z � Q AM <br /> SPM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r "7 C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> G J •Active 40 Passenger I*Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude _ 0 Planned 0 OTR 0 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 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber Q_ <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other <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 f`- <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <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 /> 0 0 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 /> e <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities v <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators � <br /> 0 1 0 1 Other: § <br /> Comments <br /> r <br /> r/=>de.°�.� ? , rr Cy�yi' <br /> Inspection Form Included:Q <br /> Comments Included: <br /> siness ep' Signature Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACKX F E f '2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> L_i G 17 9 0 4-0 4 P1 <br />