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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 15 - 01 3 7 3 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> ;Business Profile Inspection Details <br /> TPID- �-11 p Inspection Type (Fill one) <br /> Site Suffix: t/ p2 ,p 7 (7 18 Routine Q Re-inspection Q Referral Q Observation <br /> Local ��� jO� - If Referral,choose referral type(Fill one) <br /> Identifier: C/ C.t�H EX Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> !� p Y Inspectoj <br /> Physlctt Address <br /> X5'33 % -- <br /> rl r �?�p 7 Inspection Date 061 <br /> lL`l, 71 <br /> J�ltJ Time In Time Out <br /> Business Rep Title 2 0 AM f <br /> J / / y <br /> OPM OAM <br /> (� �/p / A PM <br /> a 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 /> Active 1 Passenger .Generator 40 Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> O Q Inactive Q Truck Q Hauler ®Indoor <br /> Longitude — Q Planned Q OTR Q End-Use 1 Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment Q Retreader Dismantler __oTire 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 /> r <br /> 2 �� "•. .�. �:,. .,>'^..,....' .�.. .V a,`N, ,.k...... � %���`- a h.: '"6p.,4•r'�'�.p.�yy"S,�w'"a�„+„`v�..F r `` ,r <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires tt4 Q Ektenslon. <br /> Q !Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle * R„M ^ti (mom <br /> Q Q 114 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 /> Q Q i 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years a ?' <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 Other: § <br /> Comments <br /> GTL `s � <br /> Inspection Form Included:Q <br /> Comments Included:0 <br /> ust s Rep's S nature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK A p:j. f ,fin 62081 <br /> ■ © ■ <br /> White Copy CIWMB Yellow Copy'Operator Pink Copy:LEA <br /> C,F.;_49I_14.0 17 5 <br />