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�L Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateof edCa8lornia Survey Form - Page 1 1 6 - 1 0 1 3 2 8 6 <br /> CIWMB 181(New 04/04) <br /> Cali}omla Integrated Waste Management Board <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / / !f - O Inspection Type (Fill one) <br /> Site Suffix: .0 (a `] Routine Q Re-inspection Q Referral ®Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 6tw Q CHP Q CIWMB Q Complaint Q Educational visit Q Other <br /> Business or Facility Name <br /> RC St raiuInspected By Inspector <br /> Physical Address y 3 - / 0 <br /> t o I r Mack Ld.^_e_� <br /> SL clCll`i�/ Gd ',5,--2 Inspection Date <br /> v l5 / 0 <br /> Time In Time Out <br /> Business Rep / // Title Q AM Q AM via Grp ��^�.. O 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) (FIR all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O O Inactive Q 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 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 Q Agriculture Q Shredder Q Other — <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> I� � :• <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q 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 <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§18459.3-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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q Other. § <br /> Comments Phoned 44 Greeat weV iddCb LEA tif sfs !i;Cfr. aS 1kact ve, <br /> As. rg-piveN has hof had a,. ,fin, &,Ye 4AY <br /> u.AAa_ A .ds Ak iF ts#e tires 'are- dis��l BF Are are lads �a <br /> r hi ma bon IPFf -two S � o r vale <br /> Inspection Form Included:Q ���p /` QQ Q <br /> Comments Included:Q a- ca)u ���� /Ia d� t1(09_`q6(a <br /> Bu inessRep's Signature Phone Number jt� er Signature Phone Number <br /> INSTRUCTIONS ON BACK . IFIVIAIMIPILIE1 111273 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />