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lio Waste Tire Sulky & Inspection Report Inspection Report Number <br /> a State of Callfornla Survey Form - Page 1 1 - 1 0 Z 5 fi <br /> CIWMB 181(New 04/04) <br /> Callfornla Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �. f Inspection Type (Fill one) <br /> Site Suffix: O Routine Re-inspection Q Referral Q Observation <br /> j Local If Referral,choose referral type(Fill one) <br /> Identifier: � O CHP 0 CIWMB 0 Complaint O Educational Visit Q Other <br /> Business or Facility Name r <br /> , Inspected By / Inspector <br /> Physical Address 9 <br /> Inspection Date � jl � I -3 <br /> Time In Time Out <br /> Business Rep Title - Q AM Q AM <br /> QPM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count <br /> (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) ! (Fill all that apply) <br /> ®Active ® Passenger *Generator 0 Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> O 0Inactive Q Truck <br /> Longitude - 0 End Use Q Container <br /> O Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber Apo.J'—Q Service Station Q Hauler 0 Agriculture Q Shredder O Other t /J <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility [A.FORCEMENT:STATY-4 ------------ <br /> 1Aj HAWINGANq MANIFEST RESUIRMEN $ <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notim Of Violation Q Extension <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Cgrnpllance Medline. <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> i0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pgta I I <br /> O Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days Mequ4d for:NOV or JW7) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years _... <br /> Q 0 14 CCR§16460.2 Manifest System Requirements for Registered Waste The Haulers _ tYA�i C)1fJf llll� riforcement <br /> 0 0 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 /> '0 , 0 Other: § L'���f�4�11htill}rif}Ilt►_+ I�q-Ylglatioris _..l <br /> Comments J�I T� ��7 GZ7l( �` t.✓�%t5 41'x.°5 U^s:f - <br /> r ( tr-✓r <br /> LA-5e— '�N t'-j---9L 4'k-a. <br /> U L n /1 <br /> -f ir�� �r� G�C�4n►^r..jw```°t" f0'J <br /> 1`597L <br /> Inspection Form Included: Q <br /> Comments Include - <br /> B6 nes Re ignature Phone Number Ins p;c; <br /> 's Slgnat a Phone Number <br /> INSTRUCTIONS ON BACK GL � e� r�_ <br /> White Copy:CIWMB Yellow Copy Operator Plnk Copy:LEA <br />