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Waste Tire Su- -%y & Inspection Report Inspection Report Number <br /> L State of California <br /> CIWMB 181(teManage) Survey Form - Page 1 j 9 - 1 025656 <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: "F 3 - j 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �--� If Referral,choose referral type(Fill one) <br /> Identifier: ,� , -� CHD 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Ur,!le Fl>,4 / �� — <br /> Physical Adt�ss .j - f <br /> Inspection Date 5 t J O S- <br /> � - z�S <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> QPM QPM <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whale/PTE} ( (Fill one only) I (Fill all that apply) (Fill all that apply) ' (Fill all that apply) <br /> 46 Active 0 Passenger Is Generator 0 Outdoor <br /> 0 1 0Closed 0 Altered <br /> GPS Latitude a& Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - O End Use 0 Container <br /> 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <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 I* Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENOQ C�MENT$TATUS <br /> _._� _.. <br /> V A, HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 464 Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. C.04 4ki4Deatdilpe <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§ 18459 pati m / m 1 m <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB s{�f <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days {fl3quht3d Idr.NOV orEXTf <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 ` Q Yd(CIW1B Brllorcgmant <br /> 0 0 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities I <br /> " <br /> � t ! <br /> 7g; — k_ <br /> 0 0 14 CCR§ 18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators %3 <br /> O V 101ans <br /> O IN <br /> Other: <br /> Comments <br /> d 2-c;>6 ) 4 to <br /> Inspection Form Included: 0 � <br /> Comments Included: 0 <br /> Bus ss Re sIgnature Phone Number ns tor's Slgnat a Phone Number <br /> �.. <br /> INSTRUCTIONS ON BACK Correot' Incorrect; S �v; �E r��'a�P 4 (. I�t3 I 6208 <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />