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_ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 1 <br /> Steteer8 (New Survey Form - Page 'I- 19 - 1 4 1 3 0 6 2 <br /> CONMB 181 <br /> 181(New 01101) <br /> Cellfomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Detalis <br /> TPID- (,,� b Inspection Type (Fill one) <br /> Site Suffix: I 1 I I ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. �Qh 00, OM40 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> Bvtrke-f-}s Pafl i �lastevl"_� 3 <br /> Physical Address — I r �Yfiw Z <br /> Rio 1111�� <br /> Inspection Date <br /> D r Time In Time Out <br /> Business Rep <br /> Title <br /> 1- O AM O AM <br /> - a 6y-" 1� l O PM O PM <br /> operational Status Tire <br /> 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) 1 f <br /> ®Active ®Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler I �Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned Q 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 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 ®Other 7�$T��1►lQ I,QMgQyt <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility I <br /> Q 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 /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q a 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 /> 10, Q Other: § <br /> Comments <br /> KCk IIiC2 � Orel-----l�T indO�CpS ViQ.w�. <br /> Fire Q J C o n dj5 Crnye d, �&Jzza s_d• do- <br /> yrolafi" ha eco a Qre oar <br /> Inspection Form Included:Q — p <br /> Comments Included:Q <br /> Business Rep's "re "Pho�neNumber Ins to Ignature Phone Number <br /> INSTRUCTIONS ON BACK E )( R M P L E 1 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br /> 0705904.0329 <br />