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Waste Tire Survey & Inspection Report Inspection Report NumberStat— ■ <br /> C'1WMf 181(Nrnla Survey Form - Page 1 16 - 01 3 6 9 0 <br /> GIWMB 181(New nage <br /> California4104) <br /> Integrated Weate Management Board <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- LInspection Type (Fill one) <br /> site Suffix: Zl" - <br /> Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local // If Referral,choose referral type(Fill one) <br /> Identifier: Madre- dt&c e�1n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical Address % 10 41,/L/'lko'1 I- <br /> Li��titsL Inspection Date i /l <br /> Time In Time Out <br /> Business Rep /yam Title / 0 AM j AM <br /> 0 PM / / � J / 0 PM <br /> Operational Status Tire Type Business Role Storage Type, <br /> Tire Count(W hole/PTE) (Fill one only) (Fill all that apply) (FUI all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> 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 Q Container <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 Der ved Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityT a <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires lfo3trce Of,VzolalioQ O t Xfettslatr <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. ;.CM oC .,,pc;tdt;l". <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O j 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB .� <br /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O Q 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 �st �S? Y 9t, sa <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities 9n <br /> Q Q 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § <br /> Comments <br /> Inspection Form Included:Q c4`` r <br /> Comments Included:Q 6 O_I['.0n' <br /> Iness Rep's ignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK IIEIXIAIMIPILIEI 1112131 <br /> 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operetar Pink Copy:LEA ® ■ <br /> 0630504.0036 <br />