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=<<r Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 1 9 - 1 0 0 6 6 5 <br /> CIWMB 181(NeManagement <br /> 04/04) y <br /> Callfomla Integrated Waste anagament Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � � � _ O � Inspection Type (Fill one) <br /> Site Suffix: O Routine Q Re-Inspection Q Referral Q Observation <br /> Local ^,- / If Referral,choose referral type(Fill one) <br /> Identifier. �L J06; wkl / pilt / - Q CHP 0.CIWMB Q Complaint. Q Educational Visit 0.Other <br /> Business or Facility Name '�(yJ� V" 1."/J Inspected By Inspector <br /> 164 CORNTRv ^� ,Tp <br /> Physical Address J 9 <br /> 1515N. � Sfi - V - - <br /> Me CA Inspection Date /� � � � Q <br /> `353,3(vif <br /> Time In Time Out <br /> Business Rep Tittle` 0 1 O AM O AM <br /> kepikepi !�Q.n e h a Su-v I CL 0 PM O 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 /> Q Active s Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 4D Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility $ r R <br /> Q Q PRC§42951-Waste The Hauler Registration and Transport of Tires <br /> S' . <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. � a { <br /> PRC§42956-Registration/Decal in Vehicle "' <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 14 CCR§18459.1 a b c -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years' <br /> • •>.\' �.'• f i:.ya�;:Vis; <br /> Q .Q <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities tr <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r <br /> Q Q Other: § <br /> Comments <br /> CDn�'rme.d w i seg✓.t a e. - o a�tz 'des - <br /> q A�,( - -ire St V V IC e i S 00 V' tt: <br /> I n "red <br /> Us_.SaA w a _ KB_ <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> uainess Rep'signature Phone Number pact' s ignature Phone Number. <br /> s2� rl at�j�? 62081 <br /> 1. MIT <br /> INSTRUCTIONS ON BACK xrr sr�,vx�tatrxrt ,n.a�� . tWk E 2 <br /> �i( 3 <br /> '_g <br /> « � . <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA <br /> 0529204.0829 <br />