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o Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of 181 torula Survey Form Page 7 1 5 - 0 2 l 7 G <br /> CMNMe 181(New 04)04) � <br /> Callrornia Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile -_ Inspection Details_ — <br /> TPID- Inspection� � 5 � � � Inspection Type {Fill one} <br /> Site Suffix: —` © Ile 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 /> Physical Address �^ v � -7 <br /> 75 <br /> Inspection Date 7 / p j 0_5 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> i - Q PM PM <br /> Operational Status� The Type ( Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply)I (Fill all that apply) <br /> � I+ I+ <br /> ®Active Q Passenger Q GI enerator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ++ <br /> O I Q Inactive I Q Truck Q Hauler Q indoor <br /> Longitude Q Planned Q OTR O End-Use Q Container <br /> L -- <br /> Business Type (Fill all that apply) <br /> Q New Tire Deafer Q Auto Repair Q Trucking Fleet Q Government O 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 <br /> ' //'. l _ �i��{i�!�, ,� i I t�tl}I P i i // "` I ice/ //�✓.'i ys� �j✓i rt; '�. <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> /r y,%�,/'oyy /✓moi. <br /> ✓��s/ sir%�:�%i ;y'::.�` ,�,/-.��j•�/':i�r" <br /> O Q PRC§42956-RegistrationlDecai in Vehicle ;//•�. %;. ,'G' ? <br /> 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> 14 CCR§18459.1 a b c -Tire Program ID Number from CIWMB <br /> O .14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years �������/ <br /> %.f <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 114 CCR§1.8462-Manifest System Requirements for Tire Dealers or Waste Tire Generators � <br /> Q Q Other: § _ <br /> Comments <br /> life m►�c .'Si�C�• <br /> K� C.N _ r✓u Tf � <br /> Inspection Form Included:QQ -76 r� I <br /> Comments Included: - _ - _ Phone Number <br /> L Business R s "igna urs Phone Number In n e <br /> t i T it '' <br /> X62081 <br /> INSTRUCTIONS ON BACK i �X AAPM <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />