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Waste Tire Survey & Inspection Report Inspectfon Report Number <br /> State_ <br /> CIWMBof B1l Ne Survey Form - Page 1 1 3 - 1 0 0 6 3 2 9 <br /> CIWMB 181(New 04!04) <br /> California Integrated Waste Management Board <br /> Part A_Survvgy <br /> BLUE OR BLACK INK_PEN <br /> — -- - <br /> Business Profile Inspection-Details J <br /> TPID e 1 Inspection Type (Fill one) <br /> Site Suffix: 7 Z d 3 f ® Routine O Re-inspection O Referral O Observation <br /> Local ^� if Referral,choose referral type(Fill one) <br /> Identifier: 1�� h/� O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business o acility Name ✓ <br /> � &11, <br /> / / Inspected By Inspector <br /> 5G' G.,bl1, 45;i pU/f <br /> Physicad ess 3 <br /> �5 S <br /> Ave- <br /> Inspection Date © � / !� 0 I d f� <br /> Time In Time Out . <br /> Business Rep Title O AM O AM <br /> 0 PM Q PM <br /> j a e�ra4--g . 1>+ T�— <br /> Operational Status Tire Type Business Role ` Storage Type <br /> Tire Count(Whole/PTE) ' (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> Active Passenger ® Generator ® Outdoor <br /> O Closed O Altered <br /> GPS Latitude Q Hauler O Indoor <br /> 0 O Inactive ®Truck <br /> Longitude – i O Planned i O OTR – O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet ! Government Retreader O Dismantler tO Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> Q Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facilit Y <br /> V .`A3L(C�1EYtN1+ltlt jp� y p} +((y�[� <br /> ( lJ7lf�ANIf/.MG_IR'l i7 ... ' --' ..� ' .:' •;'J�.JI'A� �{lJfki'//' /�// '•/%y/'. <br /> O O PRC 42951 -Waste Tire Hauler Registration and Transport of Tires ' . % }' iR, <br /> O O § Registered Waste Tire Haulers. <br /> PRC 42953-Contracts with Re <br /> ' <br /> OO PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB f <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tiro Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities /�i/ r�� i%,l/'�/ ✓j ; <br /> gg <br /> ® O f 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •-i _�%-�•i f ./l ��; <br /> O 1 O Other: § ii1✓. /i . . i <br /> Comments p 4-st 1 D�._ Vim/1 �So. Wp+�. .4�r- <br /> Mo.) <br /> G�c � �,.,o,�.�-�s �' �•- <br /> C. <br /> � !c> o- +Mores t�+s'�. -�`►^e�s <br /> p►;!f;k0-P gip. <br /> Inspection Form Included;Q <br /> Comments Included:O — (� <br /> usine a Reps Signature Phone Number Ins or's Signature_ Phone Number_ <br /> INSTRUCTIONS K ` , �r `� IIIIplLll It1211 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:IEA <br />