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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of <br /> CIWMB <br /> Survey Form - Page 1 19 - 1 0 0 6 4 9 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A.Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Sites r // // -7 � O Inspection Type (Fill one) <br /> SlteSuflix: / 7 '7 / .Routine Q Re-inspection Q Referral Q Observation <br /> Local `/� / If Referral,choose referral type(Fill one) <br /> Identifier: JGrf2 �oac,�.:n ( �t��y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> 3,2 s5- Gt/ 41121_1:?�IL --- <br /> J�e R5v/J� Inspection Date D / 3 / 0 6 <br /> (�f Time In Time Out <br /> Business Rep /�- Title r 0 AM J ®AM <br /> 11zIrle Zr �/l C�l _/' ­ I / D J QPM q QPM <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) (Fill all that apply) <br /> t r Q Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GP$ Latitude Q Hauler Q Indoor <br /> 0 0 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 /> 0 '0 PRC§42951-Waste Tire Hauler Registration and Transport of Tiresr <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. ' <br /> 0 0 PRC§42956-Registration/Decal in Vehicle `'" <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Uaig �k' <br /> 0 Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days " <br /> 0 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 Q Other: § <br /> Comments ark ( � zx-- ot74'1— W41,1� <br /> /yiole 9 41aele 1"'Ok-e'e' -V-Ke.0'f' fix_ <br /> Inspection Form Included:Q <br /> Comments Included: <br /> )INgess p' SI nature Phone Number Inspector's SignaturePhone Number <br /> INSTRUCTIONS ON BACK 1EVAIMIPILIE1 111213 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br />