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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 1 9�- 41 3 7 6 4 <br /> CIWMB 181 181(New 04104) <br /> CalNomia Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Busrness Profile Inspection Details <br /> TPID � O 1 Inspection Type (Fill one) <br /> Site Suffix: J V<, YO / 18 Routine Q Re-inspection Q Referral Q Observation <br /> Local r1 If Referral,choose referral type(Fill one) <br /> Identifier: y�yl__ Q CHP Q CIWMB Q Complaint Q Educational Visit <br /> Q Other <br /> Business or Facility Name <br /> � <br /> POW 0,)< ..L►,G Inspected By Inspector <br /> . <br /> Physical Address .$ 3 T 9 - + a ' V&KA�_ Z <br /> 11 ;t qa S Vo, iJoC�t <br /> I t �'�` ^ � ^, 67 S ^-3 ) Inspection Date r^ I me 6 O 6 <br /> (1.��`,' (v/'- �L Time In `✓ Time Out <br /> Business Rep Title O AM O AM <br /> M_ <br /> O PM O PM <br /> `j Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ` (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ° U &Active Q Passenger &Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Trucker <br /> Longitude - — Q Planned OTR+f1f;- Q End-Use Q Container <br /> Business Type (Fill all that apply) 1Nt <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 •Others' <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 7Q 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 /> 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 /> 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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments I ri , - Vji , r_Ms fcic ` <br /> RDS l.tS - ►'k- �'f- <br /> ✓e r W ' are J� <br /> -let • �►_z� N� <br /> s,- <br /> Inspection FormIncluded:Q - <br /> Comments Included: <br /> 1 ss Rep's Signature Phone Number I Spector sialu nature _ one Numb r <br /> INSTRUCTIONS O BACK LIE[ 1 2 3 62081 <br /> ■ White Copy:CIWM8 Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0618604.0089 <br />