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Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> State California Survey Form - Page 1 I 7 - 01 3 3 0 4 <br /> CM'MB 181(New 04104) <br /> Calltornia 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 3 0 0 6 ! 7 *Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local H Referral,choose referral type(Fill one) <br /> Identifier: �r 73�q i rL �^7y EN1� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AddresF '/ f r <br /> Inspection Date ( r / O <br /> � s <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O 3 ' ePM 0P <br /> aCCVIL� <br /> _ Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ' 5 ®Active 0 Passenger ®Generator 9 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - - — 0 Planned ®OTR 0 End-Use 0 Container <br /> Business Type (Fill all that appy) _ -- <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder B Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 I PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 10 1 Other. § l <br /> Comments Z r� U5 -�1}e s D11Sf�G. r��v�.-� 0 - _�1r-21 �i` �D /�W►¢,� <br /> 3y53//3A M,4 _ /,zo-, s <br /> - V' ou'a�+n►- /,/� 13006!7-o I 'rte_S-Ib���.-, .��� <br /> Inspection Form Included:0ao". I, <br /> dl- <br /> Comments Included:0ZIA 4 -30— z?n <br /> nsss Rep's. nature `• Phone Number Ins s Signature Phone Number <br /> INSTRUCTIONS ON BACK I MIP11-M1 2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />