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Waste Tire Survey & Inspection Report Inspection Report Number . <br /> State of California Survey Form - Page 1 "I 7"- 1. 0 0 6 7 4 .5 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> BusinessProfile Inspection Details- <br /> TPID- Inspection Type.(Fill one) <br /> Site Suffix: + (^ A 4 'k <br /> ®Routine tO'Re-inspection O Referral O Observation <br /> Lelp f` If Referral,choose referral type(Fill one) ` <br /> Identifier: SCK J ot��j,(��w lex^ �y <br /> 0 CHP OCIWMB OCom Complaint <br /> O Educational Visit. O Other <br /> Business or Facility Name -- <br /> � � Inspected By Inspector <br /> Physi al AddressM� �� <br /> 3 1 — b ` <br /> -T <br /> CA Inspection Date��3� 1 7 <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> ,Q t9 217 ®PM O S ®PM <br /> Operational Status:Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t7 (Fill one only) (Fill all that apply) (Fill allthatapply) (Fill all that apply) <br /> Active Passenger® ® g ®Generator ®Outdoor <br /> O O Closed tO Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> o tO inactive O Truck <br /> Longitude _ O Planned O OTR' O End-Use O Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer O Auto Repair Q Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> 0 Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Lull '76 <br /> ME <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> . i <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. � 4 <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements y <br /> O O 14 CCR§18459:1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 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 esi Forms and Tire Tr p Logs f ears x - c <br /> O O 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 `t- <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators " <br /> O 1 O Other: <br /> Comments MDQ <br /> `tom--sTS M A.:w a.Clr�cr�` �O�C �t-�GGt.�rS p 'L t71C��.�Z 6C��� ZOo� s <br /> (.czg�c lJagSC sic r��rc_w,P t,�i2S� L�u� pvl L Lk. h <br /> ���� .�v�I \.,t.,���. .1N ams t t•`1'+•-s of a<� Yl,,.t � �l�� <br /> vir TL <br /> Inspection Form Included:O ^ o <br /> Comments Included:O t41b �/� �� oac7 <br /> usess Re s Si Pn <br /> ' 9_ Phone Number spectors Signature.. . phone NumberW-WS ' <br /> EWA`- �"��` `� � � � � �. �� �. � 62081 <br /> INSTRUCTIONS ON BACK3~' <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA © ■ <br /> 0529204.1049 <br />