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Waste Tire Survey & Inspection Report Inspection Report NumberState Of ■ <br /> ClWM8181(era'a Survey Form - Page 1 1 8 . 1 Q 1 3 8 Q Q <br /> CIWMB 181(New 04104) <br /> CaliFomla Integrated Waste Management Board <br /> Part A-Survey BLU_E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- //'� Inspection Type (Fill one) <br /> Site Suffix: 1 0 3 lJ ( .Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � Jpl (,{,tfjL C� Q CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �/1//�1 res - I ra e� q - I 0 I i f pn.,�(,� <br /> Physical Address <br /> r Inspection Date 0 ? I l / I 0 <br /> 04 9,3�� b <br /> I Time In Time Out <br /> Business Rep — Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 L (6 Active ®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 /> i <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 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§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§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 <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: § y�.•! /' f-� <br /> Comments w o l VNO TLC �K� <br /> f1Sd6d IL_'_� L✓��'Lvt. <br /> coc <br /> fir s vi ewe TQC <br /> a/ on r in la � 6VJ. Mag a", Irlayoif <br /> in h f Zf- <br /> Inspection <br /> Form included:0 <br /> Comments Included:0 <br /> Business Rep' Signature Phone Number k1sIfector's nature hone Number <br /> INSTRUCTIONS ON BACK LE 1 X I A IMI P I L I E I <br /> 62081 <br /> 0 White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA 0 <br /> 0622104.0021 ® <br />