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Waste Tire Survey & Inspection Report Inspection Report NumberState . <br /> CfWMBf 181(Now <br /> Survey Form - Page 1 1 1 . 1 0 1 3 1 2 8 <br /> CIWMB 701(New nage <br /> Calffomia Integrated Waste Management 9oartl <br /> 'art A.Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I - C) ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �QA _,J0QG�l,(.�j'1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Tj <br /> Inspected By Inspector <br /> �'�Ock'}'ot1 JztC.Pan�-etr- �;�1(�htSk��of� 2 <br /> Physical Address J C1 - ' O ' Ten RldZ <br /> (�3(�`i Sr Llnd �ti St <br /> Inspection Date 0 6 <br /> Time In v` Time Out <br /> Business Rep Title Q �l CI OAM Q AM <br /> is PM Clli � ' ! 7 �PM <br /> Lj <br /> - I 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 /> t f ®Active Q Passenger O Generator Q Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> ;/ <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 Q Trucking Fleet 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 /> r <br /> Q Service Station Q Hauler Q Agriculture Q Shredder .Other r(n,�` {rV,('e, <br /> i <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§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments ' <br /> Aujiinv- irLs�f 0n__` s Ct0,l4.� 1Z IIOKI; Wds hoed IIS Ftci1;V S <br /> � 21 - <br /> a -fnr 5ervicz bitQn <br /> - SSC Vpr Fou✓'gas fvr5' <br /> a&LA +f M horfers, have 6ero i e eJ- 41_-Gt1 i 1 Wy� kw_ Tire , h owew_r n o <br /> .si-.e +irg S ars spr ole Sid. ae l:rc Pr ra r►� �olr� <br /> Inspection Form Included:Q�� \J_ "I D�� /L � / <br /> Comments Included:Q `�� 1`769-'7966 <br /> Business Rep's Signature Phone Number tInctor's i ature iJ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK i� ~ J I EMI P L I E1 11[2 131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ■ <br /> 0609004.0053 <br />