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jjWaste Tire Survey & Inspection Report Inspection Report NumberState . <br /> CIWMB 181(Calffumia Survey Form - Page 1 1 7 - 1 0 1 0 7 4 7 <br /> CIWMB 181 stew OM01) <br /> Csllfomla Integrated Waste Management Boartl <br /> Part A.Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> i <br /> TPID- I O - Q Inspection Type (Fill one) <br /> Site Suffix: ®Routine QRe-inspection QReferral <br /> Q Observation <br /> LocalOQ If Referral,choose referral hype(Fill one) <br /> Identifier: Lam""� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U <br /> �ei ,� , , + Vim, Inspected By Inspector <br /> Physical Address `Wt/V W V 39 <br /> 1550 W- Premen-' <br /> 0* q-5,;203 Inspection Date D a / <br /> Time In Time Out <br /> Business Rep Title <br /> _ O AM Q AM <br /> 0P 0 PM <br /> sirlG far Y(kdi0h� tA1J <br /> - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill ail that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active ®Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> O ®Inactive Q Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <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 ®Other PKI J61tj rfed <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <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 Q Other: § <br /> Comments RUI.0(XL was Yl. ia: lk�5 <br /> 6s fleet vekaks sea-uica a_f 1ocaQ_vei4d&-9. M6 on Q4;t are_ on r'i nom(/ <br /> ted kepi A- spare "tivrS Fir ✓e cles. ,c�u'95est lo inach'vAc irk S iS <br /> pLrpo es. No via laj*E <br /> 'Inspection Form Included:Q' i <br /> : <br /> _-"3�� net IncludedQ H!T s Business Rep's Slgnatty6 Phone Number ' ure <br /> Phone Number <br /> p 1 i Hih I f 62081 <br /> ■ INSTRUCTIONS ON BACK '� III, t✓ �EIXIAIMI PIL I E I 112131 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 0719304.0046 <br />