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lS3- <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> ir State of California <br /> CIWMI3181(New 04/04) Survey Form - Page 1 t 9 - 1 0 0 6 4 1 7 <br /> California Integrated Waste Management Board <br /> PartA-Surve BLUE OR BLACK INK PEN <br /> BusinessProfile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> P ysical Addres <br /> 73o 5�r �4���s A- _ <br /> Inspection Date 0 y / > / D51 <br /> Time In Time Out <br /> Business Rep Title Q AM O AM <br /> �/( 1, /� 2— ' / ;L- ®PM �'" % IPM <br /> Operational Status -The Type : Business Role Storage Type - <br /> Tire Count(W hole/PTE) O. (Fill one only)' (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active Q-Passenger '0 Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor. <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ¢ ` <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. # <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entitles Complying with Manifesting Requirements rr <br /> Q i 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB r 4 <br /> Q Q 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 <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers & <br /> 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 - \� AC,j G�Vv�M6- Entero <br /> AM K13 <br /> A-0 -11%A^Ak t rr tee In <br /> o' \ -r- y.o 4` <br /> Inspection Form Included:Q 9� <br /> Comments Included:Qct �39� � <br /> Business Rep's Signature Phone Number is Si Phone Number - <br /> 5y 62081 <br /> INSTRUCTIONS ON BACK <br /> ■ ; White Copy CIWMB Yellow Copy Operator Pink Copy.LEA ■ <br /> 0529204.0874 <br />