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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CfwM 181'New Survey Form Page 1 1 8 - 1013569 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Ins peetion Details <br /> TPID- r� I ^ _ © ' Inspection Type (Fill one) <br /> Site Suffix: /� 't Routine Re-inspection Referral <br /> _-_ � Q P Q Q Observation <br /> Local — �! � !f Referral,choose referral type(Fill one) <br /> � <br /> Identifier: jciaC T(o1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � Inspected By Inspector <br /> t <br /> vepi <br /> Physical Address <br /> '90) N. Sfo(hbkt Sf' - <br /> - I ` ^+ q,52-V0 Inspection Date D jo / �j g / b <br /> C Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 0 PM 0 PM <br /> Operational Status I Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /_ (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> (y ®Active ®Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude - Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all thatpply) <br /> Q New Tire Dealer Auto Repair Q Trucking Fleet Q Government Q Retreader o Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber 1 _'p <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other ti keAw0 P`iJtt s <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility TtNINAFt�S'` J' <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires titice Of Yiolatia2 EX4ene tpttti <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Cpnlptiano,Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB Cl / s <br /> Ea aWF <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days d fQr Nps 4; <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <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 fs _ a r <br /> Q Q Other: § � tl�ft3§b.�� '� � <br /> yrs< xa ; <br /> Comments ka,;{itn n .f}r{L(»tY� 'T (.fQ 1 Q S o -rf. 'j, �I ; �7 <br /> F(1124kh �Paf'+,,S out aft-h4 `ve s A Isttonemkan. La `Kan A Kus, —(.[hats <br /> o12+�ra�-ed w ware UOV& 04tao-wo from m p•�v�o KJner a 803 A). St ek-lT i <br /> ih r /40 *Vvs '6uciccL + im e o ofo�w'�+M5' <br /> Inspection Form InccAkluded:Q `— <br /> 5 <br /> c <br /> d:Q <br /> usines <br /> Comments Include � � <br /> Bs ep's Signature' Phone Number. 1 p tor's SigAature _ U Phone Number <br /> INSTRUCTIONS ON BACK llil z 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0 E.'_24 9 A 4. 1711 <br />