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rr <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California '� <br /> CIWMe 181 INew 04M) Survey Form - Page 1 4 - 1 0 06 ` 5 9 <br /> California Integrated Waate Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID- Inspection- O Inspection Type (Fill one) <br /> SRO Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local S If Referral,choose referral type(Fill one) <br /> r: _S <br /> Identifieak,_T404 u f Qp! , ,�c� Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> { SOS N av Y l�r f t3 - 0 ( ft,� 32 ttt Z <br /> hysical Address <br /> - <br /> J47-E- &r v I�--L•� n epa r Inspection Date Q q / L3 E- <br /> Time In 6 Time Out <br /> BusinessW KI Rep (� Title 0 I <br /> AM I AM <br /> bAd V- Q VJnix- I a! ` 0 PM � � 0 PM <br /> Operational Status TireType Business Role Storage Type <br /> Tire Count(V1lhole/PTE) r (Fill one only) (Fill all that apply) (Fill all that apply) (FIA all that apply) <br /> tf! `Active Passenger 1 Generator 0 Outdoor <br /> O 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 /> � J <br /> Business Type (Fill all that apply) <br /> Q New The Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel 1 <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber p- <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder Is Other Trite <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 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 /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q 1 Other: § // 3 <br /> Comments ih 7Oj� I QS i)'Wf4d `3 <br /> fuediluuses W17zMW1&W7d'�-&na -SM fee, bdA �i.sh/cat. 'fD ha..c,O 1&.4s awee orfwf <br /> Pr Monte, 650 Wales an s4e art- Ste- *WS a,,d /0 art. ?o &e <br /> V i eWCc( WNV an &RepW'. S_lgnat <br /> nt u S C4'A d.1S G.f,S -NO Vt o/ani' 7, <br /> Inspection Form Included: y�"�1521�*Inspore's <br /> c <br /> Comments Included: -slness Phone Number tura Phone Number <br /> INSTRUCTIONS ON BACK E X A M PILIE12 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA, ® ■ <br /> 0600404.0037 <br />