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im <br /> Waste <br /> Tire Suiky & Inspection Report Inspection Report Number <br /> Stale of California <br /> CIWMB187(Now 04104) Survey Form - Page 1 I 1 - 1 01 4 70 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t , D (j 7S 0 , foutine 1* Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: I O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name IInspected By Inspector <br /> Physlca dd ess - r <br /> f G ticae� <br /> 133 rte, t u�rW��f �ZC <br /> LA Inspection Date / V <br /> D fWJ� <br /> I Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> { 0 P QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> i(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> f ® Active Passenger ® Generator Outdoor <br /> 0 I <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck i <br /> Longitude - 10 Planned Q OTR O End-Use Q Container <br /> i <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 ENF9991kMMNIATATU., <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Natlee:af VlalatlAn Extaritii9la <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. GQmlpllfanae IttiAflllil6 <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 - Responsible Entities Complying with Manifesting Requirements D; <br /> OO 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 (R�gUln9d_TOCNi3lftrXT} <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years A <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Ftpfelt9il jIIA/hICtltff{#Akttfttf <br /> O Q 14 CCR§ 18461 Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ' ' a/ <br /> Other. § .-:�..,.•_. ,_, /`- !.1''II <br /> Comments h <br /> �\t\ w•. �.-s-S� C T1s I r h u�n�c.t.� L�-al �( I 7.tc, <br /> Inspection Form Included: Q _ <br /> Comments Included: I <br /> QI Business Rep's Signature Phone Number Inspe or's Signat Phone Number <br /> INSTRUCTIONS ON BACK Correct.--* Inill *: t S � E X A rA EI �Z j 213 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />