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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Srgmeo}California Survey Form - Page 1 1 4 - 1 0 1 3 7 8 8 <br /> CM/M8 181(New 04104) <br /> California Integrated Waste Managamont Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business,Profile - Inspection.Detalls <br /> TPID- Inspection Type (Fill one) <br /> SRO SuffbL ► (o $ a $ - o <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> Local �Q /� If Referral,choose referral type(Fill one) <br /> Identifier. ►\—N�-�- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> :�*rSfn�e I ori, Inspected By Inspector <br /> Physical Address 3 1 - ' b ' I <br /> bad Mar, h'4lw� fir, <br /> TInspection Date O /_ ' Z O�� Time In 1(J Time Out <br /> Business Rep Title Q AM Q AM <br /> LAn �A_1_ Jt 0 PM Q PM <br /> 'YW r(y�� Operational Status Tire Type . g Business Role Storage Type. <br /> Tire Count(Whole/PTE) Qy / (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> l 0 Active Q Passenger •Generator f Outdoor <br /> OQ Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ilf Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) - <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet p 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 Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> a i i <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires 1, <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. r� 1 <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 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§1B459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 101 Q 1 Other: § <br /> Comments <br /> Sh EX. 206C �►'uc�S J ITz� s f� �►W 13011 1 <br /> < <br /> 14M, rAiffiftA , vl�lta.�t�ns. <br /> Inspection For Included:Q ��jj r Zl� <br /> Comments Included:Q `''s is[ 4pe:,��& <br /> ` �996 <br /> Business Rep's Signature phone Number gnattue . Phone Number <br /> ■ INSTRUCTIONS ON BACK jIEjX A A4 P E 11[2131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0618604.0027 <br />