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«< Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of 81(Nrnla Survey Form - Page 1 1 7 - 1 O Z 7 9 4 <br /> CIWMB 181(New 04100.) <br /> California Integrated Waste Management Board <br /> Part A-_Survey BLUE OR BLACK INK PEN <br /> Business ProflIs Inspection Detajls <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ( (�- O // O 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local ( �` T If Referral,choose referral type(Fill one) <br /> Identifier: 5 �{7�„_-� C 11 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J �./ Inspected By Inspector <br /> oi <br /> Physical Address ! <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> WweR <br /> -_� t:3 Operational Status Tire Type Business Role I Storage Type <br /> Tire Count (Whole[PTE) (Fill one only) (Fill all that apply) (Fill all that apply) I (Fill all that apply) <br /> 2-00 • Active Passenger • Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Container <br /> Business Type (Fill all that apply) <br /> e 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B Inspection of Waste The Dealer, Generator, Hauler and End Use Faculty ; TATUS <br /> lol� on Q.extsnslon <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle ' <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements { I I m <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2,1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days d_ fNOYtN 19CT3 <br /> Q O 14 CCR§18459.3-Retention 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 ;i [ �iR1QtC9lgRrlt <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ` t <br /> Q O Other: § - <br /> Comments L VOLhhG L. 94&- rt7� Hyl +�.T�- - - �jo /,( S�-5 -- <br /> ri' I r•� J�--J$/fes�. �A S'�- ��� CI rG. - �''� 1 i� G '�"Y'�r��r-- <br /> At <br /> !7 �1� ri wS r`'r f�)�{�.a f t.�J/f/a/ 6&- <br /> ,inspection <br /> &.Inspection Form Included: Q <br /> Comments Included: Q — - <br /> f s 's Signature 'Phone Number tors Sign a Phone Number <br /> ,.id it iv' •f�`rr� --t 62081 <br /> INSTRUCTIONS ON BACK AMFPI 2 3 <br /> Entered While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> KB <br />