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1 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> L99 State of California <br /> ■ <br /> CIWMB 181(Now 04/04) Survey Form - Page 1 V - 10 G � V 0 y <br /> California Integrated Waste Management Board <br /> Part A-Survey_ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- l �� f� - Inspection Type (Fill one) <br /> Site Suffix: I '19 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. Q,yl O CHP Q CIWMB Q Complaint Q Educational Visit lt�'Other <br /> Business or Facility Name Inspected By Inspector <br /> Cq.li rnit� Rock Ci-L,61,e., <br /> Physical Address �� 'Z <br /> `73f� 3, S�ockfa�. <br /> J�IPDk'1 Coq �53b, Inspection Date j C1 / <br /> Time In Time Out <br /> Business <br /> Rep <br /> � Title 1� � � � h 0 AM � � � � Q AM <br /> Karr c�• �4Ce �l� V UPM aPM <br /> Operational Status Tire Type. Business Role Storage Type <br /> Tire Count(Whole/PTE) 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4 Active ®Passenger 0 Generator O Outdoor. <br /> O Closed Q Altered... <br /> GPS Latitude O Hauler Q Indoor <br /> O O Inactive J#Truck <br /> Longitude - Q Plarined OF OTR 0 End-Use Q container <br /> Business Type (FIII all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 0 Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body 0.Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other 1-4p�,;,l c�/�Utsryte_h <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility �1 c � s <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires h <br /> O Q PRC§42953-Contracts With Registered Waste Tire Haulers. t. F <br /> O Q PRC§42956-Registration/Decal in Vehicle 4 ' <br /> O O 14 CCR§18459 -Responsible.Entities Complying with Manifesting Requirements 5 y?< <br /> s y: rn <br /> Q 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 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 =� A•` n " .'� ' y1 <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste.Tire Haulers . . ) ti <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire.End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators10 1 tis <br /> Q 1 Other..§ i'6 r i/ co. <br /> Comments�,.,�_1ph 4-N51 d0_14 Qi'�� WLe- I!O W I!Cq talk S nof'eyf' _ k� a <br /> FaeilL-hv 0�;Rces 1wr'a-f-ed C& &oGtif e-s,s. G'Sihe-SS Opet-ate, +eA-tp- <br /> or&--y jC16 .sits kr crwsW" rocK-sl V&Wble-s ih-VDIve-d are helwy 94tp- <br /> -Mewv+ '"!t'A +ra-cks •fi-rd '✓' loode.-s aAd jqq4sen9.er ✓elz;e'er <br /> Inspection Form Included:Q k p <br /> Comments Included:(Ib 46A"'o�` '"-0'4 � <br /> "'aq-C,��L <br /> Business Rep's Signature Phone Number Ins lector' ignature. -Phone Number <br /> INSTRUCTIONS ON BACK rrect lnccirrect f Er � ). 4 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator _ Pink Copy:LE © ■ <br /> 05 21F14. 1167 <br />