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t., <br /> Waste Tire Survey & Inspection Report Inspection Report NumberStat— ■ <br /> rlr <br /> CIWMB181(Nrnla Survey Form - Page 1 4 - d Q 2 1 <br /> CIWMB 787(New raga) <br /> California Integrated Waste Management Board <br /> PartA-Survey___ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> i TPID- ^ - ' Inspection Type (Fill one) <br /> ffi <br /> §itesux: O( ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: cLf�.',- , /) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> A1JI cued Rei"t Rd �WV' 2s 3 - I o <br /> Physical Address \�p �p <br /> -Bo � vc. 4es Ale ,, - <br /> Ma4q`­e-Co- q 5 33Co Inspection Date C) I? / O / <br /> Time In <br /> Time Out <br /> Business Rep Title O AM <br /> O AM <br /> O el CL Tj0LA.;1 C . a^ <br /> O PM O PM <br /> IF V 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 /> r Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude O losedQ Altered <br /> GPS <br /> Q Hauler Q Indoor <br /> inactive Q Truck <br /> Longitude O <br /> 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 /> fit ' <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ~ � <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires * <br /> - e `' .' _`'°"'"• '' `psi=' <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 Entities Complying with Manifesting Requirements �r <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ` 4, <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> i -camT <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 1010 Other. § .v Vii'om WW7��I' <br /> Comments RoxA lQi lefts • Fat U-De-S 110f 99oMA le c$h . <br /> Fn r I-J aee vIIII'l s ate. <br /> g—_WarekDVSC. ReCDr_nOM ID ilt4t Vai-e- <br /> T�1I� <br /> Inspection Form Included:Q �RePsSlgnature <br /> �� <br /> Comments Included: - 7� -9!BPhone Number I pr toes ig tature Phone Number <br /> ■ INSTRUCTIONS ON BACK X A MP1- EI � � 62081 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0723504.0168 <br />