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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State B Calif role } Survey Form - Page 1 15 - 1 0 2 6 4 4 <br /> CIWMB 181 Now 04!114 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile II Inspection Detpils <br /> TPID- / t� - Inspection Type (Fill one) <br /> Site Suffix: (t1 ! f ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t <br /> Inspected By Inspector <br /> Latz o T7 I re '9 or 2, , <br /> Physical Address J <br /> I <br /> Inspection Date , D V / e S <br /> Time In Time Out <br /> Business Rep Title () AM Q AM <br /> \ rte 0 PM O PM <br /> "CJU t o 2r r v �7� w <br /> / ,Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) J , (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t v # Active ! ® Passenger ® Generator 0 Outdoor <br /> 0 Q Closed 0 Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair 0 Trucking Fleet QGovernment Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture O Shredder Q Other <br /> Part 8- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility � 14T[STATUS�__,_.___.__ � <br /> a E4NQMq-M4NIFKST R ?BUIf Mt NTB tlon Q extension <br /> Q PRC 0 R§ Registration and Transport of Tires O Vlolit� <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. 00, paillffie <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs Within 90 days dtbf NOVOrQlT) <br /> 0 (0 14 CCR§18459,3Rets entio of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers - } � Snfo�cginitt <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .s <br /> O O Other: § <br /> Comments NaAj Fz*� irov I dw `'' Qki PAS re-c-f 1 on J rum 51Qile4 -Yre Aauter- - <br /> G�Y r .J w akt,+ e5fs 6r 3 <br /> 11a (I a. Qca f s r�o�o�) FnaS� v>-,o►�It eta�t <br /> V tars f r i n-sp ecfioh Wood f-i re rac_s heed- -k) be rep he Rci <br /> Cu5 M(WS . yay�,�% k� fres. rack& _oa � . VeS2U, J <br /> Inspection Form Included: Q <br /> Comments Included: Q IMe�� �� — - - I Vag_6�7 6 <br /> Business Rep's Signature Phone Number In a or's I a ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I t�Rlq �f> 1 ��\/ r0.ItNV�P L�:LI . 2 3 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />