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L= Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State California Survey Form - Page 1 3 - 1 0 1 3 7 2 1 <br /> CIWMBR 181 stew ed/ebl <br /> Callfomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> (Business Profile Inspection Details <br /> TPID_ r? (0 _ O r Inspection Type (Fill one) <br /> Site Suffix: l 9 1 ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalC" If Referral,choose referral type(Fill one) <br /> Identifier: �DQl Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - <br /> t � Inspected By Inspector <br /> !�0-V G t s lk ki per 3 - ! 0 1 <br /> Physical Address v r <br /> 4kF—y V), OA 7,5 g(/,S— Inspection Date a ! 0 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 19,er,r 1 e,Ba.l Ct 0 A� pM U�( — 0 PM O PM <br /> -- — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ®Active Q Passenger *Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 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 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 fY1.tG� 1'�Qta 1 r <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§1 B462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § �/,J / �► [ <br /> comments ,,,�-,,.,n /i Cn��. 7 Yt�(s .[�&q , 'lilt l�U_� I/L� s.$ fouled <br /> _'rrL_ ylee Pet^ M-e_cQ 6 S;h9k,sTy-e liizo vley-d ed . -f ous- <br /> po_Sa,Q of l�)aSi - ireS- �I LTR f►, Jme- 2005, 1�1t2rt� Z rte/l d,NO t��a lczyta,� <br /> Inspection Form Included:Q t 4 ( lp)/ /y 7�) r�9)p <br /> Comments Included:Q (J�,/�t V qW—+y � --- -7��a--- <br /> PhoneBuslness Rep's Signature Phone Number I or's ature Number <br /> INSTRUCTIONS ON BACK t+ o,ril o I IEIXrAIMIPILIE1 III I 62081 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� ■ <br /> 0609004.0335 <br />