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Waste Tire SL*ey & Inspection Repot* <br /> Inspection Report Number <br /> State B 181 forni Now O V V <br /> Cgrated asteMaage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ _ __BLUE OR BLACK INK PEN <br /> +Business Profile Inspection Details <br /> TPID- ---7 Inspection Type (Fill one) <br /> Site Suffix: 1 3 -75 Ci q 5 3 © I Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ��., If Referral,choose referral type(Fill one) <br /> Identifier: �qh rola Ht� -�� r"JgD Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L: Inspected By Inspector <br /> Ph sical Address <br /> �t��l int/'• <br /> U ?, Gl <br /> Inspection Date © /' ' � 2— I © r <br /> Time In Q Time Out <br /> Business Rep Title O AM O AM <br /> �' V____ 0 PM Q PM <br /> - - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill a))that apply) <br /> 0 Active Q Passenger ® Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive ®Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) - - <br /> Q New Tire Dealer Q Auto Repair 0 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> -.S t �.J. �,F1'�i�M�E'�Rfl)1 �����'/1,1�:�i4w>-�4Ti112�9 /i �/ - ,f '���/ �fj��/�j ii%/ i�/,�.✓///��%fl <br /> PRC 42951 -Waste Tire Hauler Registration and Transport of Tires �ill%i, ,n�., <br /> ,.i/�/�.�%✓'l%jii',��/-• <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. , i <br /> i;;urn <br /> PRC§42956-Regis tra lion/Decal in Vehicle �r�"�'''`�'%:!%'� ''"``�/R, �� <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459 .1 -Submittal of Manifest FormLogs <br /> .2 sand Tire Tri within 9d <br /> 14 CCR§ 18459.3 Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O 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, r'f�%� � a //" %�' •'/moi; <br /> Q Q Other: § <br /> Comments <br /> j)r fin'+-� 7� <br /> c�K� ��9 t' Q� (.✓�n8' /'� / re-4 �-/ Gil/rte C:7 <br /> /'�-1t�'`� �:r�Jt� d►". �'�r pS dY'. lsi� � G�-�'r�-- I�"'a^+ S�9*1'��(r.ctGr�r�^�sr <br /> Inspection Form Included: Q <br /> Comments Included: Q - '' <br /> siness Rep's'Signature Phone Num�/�b;er _ Ins XX Actor's Signature Phone Number <br /> �r i/�/ ,✓'//r�,�/i,�ii%�.�/ /' i� G, "-/J --' 62081 <br /> INSTRUCTIONS ON BACK ,1 r C ; ,1, I 1. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />