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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> Stat 7181(Ne <br /> Survey Form - Page 1 1 9 - 1 0 0 6 3 6 7 <br /> CIWMe tea(New 04/04) <br /> Callfomle Integratetl Waste Management Board <br /> Part A.Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details. <br /> } TPID- �r o - Inspection Type (Fill one) <br /> Site Suffix: I 7i Q i Z j I&Routine Q Re-inspection Q Referral Q Observation <br /> Loral If Referral,choose referral type(Fill one) <br /> Identifier: Gam-eN.- �h /,_ ��� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> ,�. <br /> prr.,,`� Inspection Date 7 <br /> -`�Gvs Time In / Time Out <br /> Business Rep Title O AM Q AM <br /> I Z 9 PM Z ' / B PM <br /> Nlvk' I��i i baY-(cs-- S'InQr.-,iKw� �;�-� <br /> —Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) ©O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' a 0 Active *Passenger 0Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> O 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 ®Other �jNg F/gyp <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 f 6 <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB v <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 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § /+ <br /> Comments V1� 'to,��r� --�.-s <br /> F. // r d Q 5 rrto r' yYi LMgr�rK75s ttS �V91��e.61G k9f- Y+!IJr'P r�/� e� - . <br /> ,�• <Gat�oQrl�ix _ 4� <br /> � l <br /> i..co,,«7�,r - 'i, w�ar•(�'es l�o..st'�c- rn JZ�lh 929:Tv/ <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> ��Busine"Repf"st <br /> G Signature Phone Number o s gnat a Phone Number <br /> INSTRUCTIONS ON BACK " JE IAIMI P I L I E 1 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 0600404.0526 <br />