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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 1 4 - 10 13 2 5 1 <br /> CIWMa 181(New 04104) <br /> Califomla Integrated Waste Management Board <br /> Sart A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 9 Inspection Type (Fill one) <br /> Site Suffix: 6 -7 S (9 Routine 0 Re-Inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Phy4rC51 Address <br /> �z3 Le-1 /�Q <br /> Gy C 9 S-373 b Inspection Date / Q <br /> Time In Time Out! <br /> Business Rep Title 0 AM 0 AM <br /> 0P 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) �C O <br /> ®Active ®Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other �►'2�, g � <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> LL <br /> 0 .0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 !PRC§42953-Contracts with Registered Waste Tire Haulers. - <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days - <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers - <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § I_ eo <br /> SEEM- <br /> Comments <br /> O�v{�'. �--L-�-��1�— T"'� !—°`V��.•� � wnl`L�f �oun�5 �rin' �� -�v..�s✓S U Q <br /> -A, ,�-, ,.",l,t-Ic- 5��fe-.. �i'TLs A..w,L htnh''a,-�K• .1 .--�r~Go'-�^-`j '"TIY�-s o„�.- 1ww'-+T� <br /> DY U!'� � <br /> Inspection Form Included:QA <br /> Comments - - - <br /> Business Rep's Signature Phone Number Ins tor's I at re Phone Number <br /> INSTRUCTIONS ON BACK uV JEJ)�AjMjPjLjEj 1112131 62081 <br /> ■ 0716504.0026 White Copy:CIWM8 Yellow Copy: Aerator o ® ■ <br /> Pink Copy:LEA <br />