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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ce. <br /> CIWM 181(ornia Survey Form - Page 1 l y - 1 0 0 6 3 6 3 <br /> Cgmte 191(New94194) <br /> CalHomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection 4 Inspection Type (Fill one) <br /> Site Suffix: `( O J e Routine Q Re-inspection Q Referral Q Observation <br /> Local �y / If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name - - — <br /> Inspected By Inspector <br /> 1h¢�r11C�` tV2v. o ' <br /> Physical Address <br /> 4-0 Inspection Date Q <br /> Time In Time Out <br /> i <br /> Business Rep Title O O AM O AM <br /> OPM PM <br /> tec <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' 1b Active ®Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> o New Tire Dealer I*Auto Repair Q Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility t �" <br /> ,T.x y- :,iur- - c> ­1" <br /> .__ .. ,moi/ •'„ �''i�`F •�' .��3?S. i 3. y,J , <br /> O Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires 1 q y a• <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMBr rysh <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days ?r3; o <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for'Registered.Waste Tire Haulers .} <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O LO <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Other: § <br /> Comments0C <br /> -�" r�Sr"/'G_ �r�� �5 �t� �„t✓O�re.�l D^t- 'T't►-�S by <br /> Ente eo <br /> —4Lcit ��.� �nv1c n••- G.. o was -�tr�s 6e f;..a <br /> Inspection FormIncluded:0_/ ,xel �q <br /> Comments Included: � <br /> Business Rep's,Signature Phone Number 1 for Sign Lure Phone Number _ <br /> INSTRUCTIONS ON BACK in 2 s L Fj;jAjMjPj 62081 <br /> ■ White Copy:CIW MB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0529264. 1187 <br />