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u-iWaste Tire Survey & Inspection ReportInspection Report Number <br /> State of California Survey Form - Page 1 I - 1 0 1 0 6 3 <br /> CIWMa 181 tew 04104) <br /> Califomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile - - Inspection-Details <br /> TPID- 3 q n r� - O Inspection Type (Fill one) <br /> Site Suffix: `7 J ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. &ellQ( y jA Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �/1 <br /> Inspected By Inspector <br /> D.P HoA S�v) 3 _ C) l <br /> Physical Address ', V0 D <br /> C�9 YS"0 7�b►'rl f n ( - h <br /> C Inspection Date <br /> C a�f C•4 "�'� ���3 <br /> / Time In Time Out <br /> Business Rep TitleO AM O AM <br /> 4 i g 4omn� b( qr4 OWW O PM O <br /> PM <br /> -- Operational Status Tire Type Business is Storage Type <br /> Tire Count(Whole/PTE) I f `� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> -/ ®Active Q Passenger (&Generator ®Outdoor <br /> 0 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 that apply) <br /> Q New Tire Dealer Q Auto Repair tD 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 <br /> �n <br /> Q Q 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 /> R <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements F ' <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 a � <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 /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § ' <br /> Comments RDIX r t irUfCC.&A 7Ai S da* c CIu1f' A IAJ424 !1 SfS —1�S Sik-_ tli <br /> i'F' i 0 '✓t �f'l�. �t.C� 0 ctZeS <br /> fzs ayup�&— r filso ovUK&r— +^ r n eta <br /> -mb*S, If , /U C s J°9e f - t dc's <br /> Inspection Form Included:Q J� <br /> Comments Included:Q L7q -`/1 <br /> Bu Ph ..Number " <br /> OS <br /> s ' - r <br /> e.SlPhone Number <br /> INSTRUCTIONS ON BACK ygP o 2 y " �' X( A AAt P I,- ,�1 3 62081 <br /> ■ While Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br /> 07081 b4.0069 <br />