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Waste Tire Survey $ Inspection Report Inspection Report Number ■ <br /> Stahel 181(NeCalifornia Survey Form - Page 1 I $ - 10 1 3 3 3 8 <br /> CIWMa 181(New nage <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q / Inspection Type (Fill one) <br /> Site Suffix: 1 $ 1 3 G 7 - z 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Ci✓ h� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name �7�f Inspected By Inspector <br /> oPhyy� �o�er/Q rc ks A,,+,, , a�� 3 9 / orddress 4 R <br /> C!5' cA c15f/n a Inspection Date Q 7 2 o -6 <br /> •— Time In Time Out <br /> Business Rep Title O AM O AM <br /> t� © o la PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' <br /> 15- 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude _ 0 Planned 0 OTR 0 End-Use 0 Container <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 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 7n0R1' §42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 §42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§16459.3-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 <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § /� n / / <br /> Comments MRni CYS1'�1eXtr�1� �5 .e< tnl <br /> Inspection Form Included:0 <br /> Comments Included:0 <br /> Buslne ep's Signature Phone Number In r s Slgn ure Phone Number <br /> INSTRUCTIONS ON BACK I EINfAlhklPLE 1 2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0605204.0526 <br />