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�i Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State California Survey Form - Page 1 1 3 - 1 0 2 5 6 <br /> CIWMBB 181(New 04104) <br /> California Integrated Waste Management Board <br /> 5 0 <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details l <br /> ;- - — <br /> TPID- J , Inspection Type (Fill one) <br /> Site Suffix: ''t' l 413 - © os <br /> Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: v. �' CHP CIWMB Complaint Educational Visit Other <br /> --�� - y �T7 ,� � � � p 0 <br /> Business or Facility Name lr <br /> Inspected By Inspector <br /> Physical Address q •,/ <br /> D,- <br /> G64 9452,o5Inspection Date <br /> �--. T <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> I ' <br /> 11 c �_nQPM QPM <br /> LA 1 S �av�� �s <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply); <br /> f f 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> ° 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> ° 0 Inactive Truck <br /> Longitude - Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 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 N. ENT I 1TATUS <br /> -IQ►-� <br /> Ili-UILINON0 M IIO$T-fi* IJIf Ni$IdTB , <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Y)illihQOn Q EktAnRlOn <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Qb I ` p�taldU !s <br /> 0 0 PRC§42956-Registration/Decal in Vehicle m <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Q0' <br /> I 11—LJ <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 trfed foN�Yt�rX7) <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 � Fit <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 ( a <br /> 0 : 0 Other: § -- <br /> g / p <br /> Comments Lj <br /> }kt7r. �^✓ y q"1 S G l l.,l a5 / f.15�•�C �1r�S <br /> �,-- <br /> hra►-•ei v�qs�-/l�t��ZQ -�'�,"'�5 �,.U. `,a,�--11�Q�._ Q�-�-- q e�,.1O,s-i� -f 1',--�. <br /> Inspection Form Included: -2 <br /> � <br /> Comments Included: � <br /> Q.�l Rep's Signature Phone Number s Signature Phone Number <br /> /i .. , rl'� 62081 <br /> L <br /> INSTRUCTIONS ON BACK k7 IT "fft7y t ,�/ a , r z 3 <br /> _ � <br /> Yellow <br /> White Copy:CIWMB Yellow Copy:Operator <br /> Pink Copy:LEA <br />