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== Waste Tire Survey & Inspection Report Inspection Report Number . <br /> rto <br /> r� State of California <br /> CIWMB 181(l 04104) Survey Form - Page 1 1 6 - 1 0 1 3 7 4 9 <br /> Callfornla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details <br /> TPID- Inspection O Inspection Type (Fill one) <br /> Site Suffix: J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> identifier: &LA- _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — <br /> Inspected By Inspector <br /> e r2�r� l�a Gl e� I rc�ytsp o,- fiz o n h C_ <br /> Physical Address 3 1 D <br /> 30l 31 S ttw y 3:E v _ <br /> Tra CCA Ti <br /> A Inspection Date D , O / O <br /> / Time In me Out <br /> Businesls_Rep� J f Tittle y� ) 0 AM Q AM <br /> i�ab V1/OOJ.S�✓� _ 5h It' (Q►� ®PM— 0P <br /> " Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W holelPTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger <br /> ®Generator &Outdoor <br /> O Q CloseQ Altered <br /> GPS Latitude d Q Hauler Q Indoor <br /> 0 Q Inactive •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 0 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility rr <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires m <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> I y.1 <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 /> rv��x off` <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years Y' <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 '3 <br /> Q Q Other: § ;h <br /> k�ta:'' <br /> Comments <br /> 1daq fog T�re <br /> �U i 5 fill `�t 5 is a A,e.t "l � � 5 l`Z� fieri ler-S, mvst <br /> ZIPw 'ch arejQrviced hwe. ear i , ,-,r ���e r s�roce and'"J <br /> ' <br /> 5i v vied, 4 YVlQt+1(� 7c� tit? V iDja:f�'t <br /> Inspection Form Included; <br /> Comments Included:Q U tgtiJ tA` �bg �� <br /> siness Reps Signature phone Number Ins s Si n t re <br /> Phone Number <br /> ■ INSTRUCTIONS ON BACK r - :r_ X a IW P 1 62081 <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> r=1=,1`1r=14. F171 <br />