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<E Waste Tire Survey & Inspection Report Inspection Report Number <br /> state r C1WMf 181(Now <br /> Survey Form - Page 'I 12 - 0 2 $ 4 <br /> C{WArt6 181(Mew 84�QJ) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> i <br /> TPiD- Inspection Type (Fill one) <br /> Site Suffix: I '1j 9 � -7 r Q Routine ®Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1 pe, CIL 67q f Q CHP Q CIWMB Q Complaint Q EUucationaf Visit Q Other <br /> G v^ v <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> l y33 L 1-;►��PSGy 54- <br /> Rf Inspection Date <br /> D� - Time In Time Out <br /> Business Rep Title OAM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill 0that apply)+ (Fill all that apply) (Fill all that apply) <br /> r ' ®Active Q Passenger ® Generator 0 Outdoor <br /> C Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> p Q Inactive 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 0 Other E34.5 F <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility lAN ORMENT STATUS__....____ <br /> Vr �, A► HAtlLINQ:A�V M141�tIF>w8T t$t+lllltii MF NTt3 ' !Q N01c4 4f.Violation Q Extenalon <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compllance:Doodiine <br /> Q I Q PRC§42956-Registration/Decal in Vehicle I . <br /> QO 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Date <br /> M <br /> _.QIO 114 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 I f��+/ for NOV Or FX7) <br /> O ! Q j 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 I Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire HaulersQ ferrRd.f.j;JIM Enforcement <br /> Q 0 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 /> id.{ripfltlr�!!t No-lJlgletianoi. <br /> —Ill Other: § <br /> Comments /�q„�•'1�'� 'f"5 �X! '� C�v►5lT�... r lG7�i'f' �-�.�•�.'f'� N^c+�t^�'C�ST� <br /> 15 f-- j ) M 6 1 '�-. !t , � 11� L 5'-'Q is <br /> Inspection Form Included: Q ?lnsctor'ts <br /> Comments Included: Q +� <br /> Business Rep's Signature Phone Number Signat re Phone Number <br /> INSTRUCTIONS ON BACK fQt1CrllCPL ?�I� 3 62081 <br /> White Copy:CfWM6 Yellow Copy:Operator Pink Copy:LEA <br /> r <br />