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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State or IN— <br /> Survey Form - Page 1 18 - 0 1 3 5 7 l <br /> CIWM181 B 181(New 041041 <br /> Cali}omia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suf b[: L�1 f 3 8 9 3 V 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sam i 1 Q CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 71� lti�i1�J3 Ir&1T <br /> Physical Address u 3 )9KA; kU 2- <br /> 7 DCO �f VJ y I�-O V G - — <br /> n C J ^ ,, ISZ6 Inspection Date <br /> K �j Time InTime Out <br /> Business Rep Title _ Q AM Q AM <br /> ° <br /> — -- rJI� PM <br /> Operational Status Tire Type PM Business Role Storage Type <br /> Tire Count(Whole/PTE) III one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger .Generator Q Outdoor <br /> 0 Q Closed Q Altered /U <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude – Q Planned 0 OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment 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 s S <br /> .,� •. .T T' - �• t7lc '�" f�,���-�'a s�Y c -e.'t�` �'x` a � tmt f-� �[tenslRtr"�',,, <br /> X <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires „«f '7 as ##�, <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. " 3 4 • <br /> Q Q PRC§42956-RegistrationlDecal in Vehicle i,; :.*, - k M <br /> _r <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 O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years l � <br /> QQ 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q <br /> 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities ����-•F r �• <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments <br /> 14*__ <br /> 4 RIO -"Q,_e ms iz, I I "' (fin �, <br /> lAS9 S vu ivt F1e .7D K✓ 2 selcilce _0j-'A <br /> 60L-1.5� 's,40'si. NCS f r 1.cCk16 <br /> JrS ', C'Z' �„'�—Or nLj <br /> word's Gam- e-moor f1e _m-�._�,�1 <br /> Inspection Form Included:Q 195-7 <br /> Comments Included:Q r � � <br /> Business ep's S gnatu Phone Number s ctor s i slurs one Num r <br /> INSTRUCTIONS ON BACK R �. E 1 a 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy:LFA ® ■ <br /> 0634704.0275 <br />