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Waste Tire SL__ ✓ey & Inspection Repo' Inspection Report Number <br /> State C1WM 181(Now Survey Form Page 1 1 8 - 1 0 2 8 8 8 3 <br /> CIWMB 181(New 44104) ,r <br /> California Integrated Waste Management Board <br /> Part A—Sure _ _ BLUE OR BLACK INK PEN <br /> Business Profile 4 _ Inspection Details <br /> TPID- 2 h In Type (Fill one) <br /> Site Suffix: 3 5 © / 3 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Gf lI— ���q �� C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Y Inspected p By Inspector <br /> (3lacLmLto � Kipvmed- L&5�V _ 1 Q 1 <br /> Physical Address <br /> Inspection Date � (; I � _2 I <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> �'1� ��' - -- <br /> -- — - — -- Operational Status The 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 Q Passenger ® Generator • Outdoor <br /> O Q Closed Q Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive (aTruck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other a�qGQ -I t�t.� De-Cd e-r f <br /> Part B - Inspection of Waste Tire Dealer, Generator, ler a <br /> Hauler and <br /> End-Use Facility <br /> .i,,, i.,. ."„x:: •r$i7�`i”= ai:i?'i'i >/. .� "i' 1 . rf%•.;�n',:�,.y;%'r.'%.. /! r :; <br /> y� ' �: ,...�� �5!�1t� � / ii, .�j.�/ is <br /> � � <br /> o o <br /> i <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle" <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 14 CCR 18459.1 a b c -Tire Program ID Number from CIWMB <br /> 0 0 <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs urithirt 90 days <br /> 14 CCR 18459.3-Retention of Manifest Forms and Tire Tri Logs for 3 ears %/ <br /> 0 0 § P 9 Y ;y <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r �' <br /> 0 0 Other: § <br /> Comments Wa- k 6f e -01)3w h W Pro ! A kiS ._w a6 f`e_ hi-0--s a mA r���$_� Afa i S-�S V ettle,� <br /> (bc_,j o s oj Sas) Rpf ysee- tires v -wedgy Y ► + ars re._ o r 4D e- re- <br /> .e� o Oho un r,�sa.h�� _�-i,�_�s s�.l�v� ~�i� oCo�, ._FFa►�oto�5 p�;s'��-b __�_c� ,_ <br /> 'Inspection Form Included: Q ` � <br /> Comments Included: Q — � l�� <br /> �� -�6 <br /> u 1 s_Re ' Ignature Phone Num er I sector's Ign ture Phone Number <br /> WIN <br /> 62081 - <br /> INSTRUCTIONS ON ACRill" �.ry/ r <br /> --:rtl4 rtl4IP L 3 <br /> Wh e Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />