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«- Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> eu <br /> State of California <br /> CIWMB 781(New Survey Form - Page 1 1 8 . 10 2 5 7 0 5 California Integrated Waste Management Beard <br /> Part A- Survey _ BLUE OR BLACK INK-PEN <br /> Business Profile _ _ Inspection Details - <br /> TPID- ` Inspection Type (Fill one) <br /> Site Suffix: 0 8 Z— <br /> Routine Q Re-inspection Q Referral Q Observation ; <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: '� �w ��� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name e 1 Inspected By Inspector <br /> 5 I tfe. <br /> P sical dress <br /> 6567 W. 51nH1� - 1�d. <br /> Inspection Date O O es If 05 <br /> rG°i `1530`1 <br /> p/ <br /> J Time In Time Out <br /> Business Reacy Title Q AM O AM <br /> O PM Q PM <br /> - - - - Operational status Tire Type Business Rale Storage Type <br /> Tire Count(Whole/PTE) (] (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)I <br /> r r ® Active ® Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude - Q Hauler Q Indoor <br /> O Q Inactive 0Truek <br /> Longitude - - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> • New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B <br /> Y - Inspection of Waste Th.)e"SDaaear}lecr, Generator, Hauler <br /> r/anEnd-Use <br /> nd Use PacllrtY <br /> R M kTTA1 $ <br /> _ ' -_ <br /> 11 Wil <br /> Q Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> Q t (( 1otl4xt Q 5#12fRn <br /> Q Q PRC 142953-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 I <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 /> H <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 <br /> 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 ?a3 4 t <br /> Q Q Other: § <br /> Comments / <br /> 1�1 � /`a�.T//1G Survcx � �rfF1���ow/,zS�'✓srS h2�i.�� <br /> Taut <br /> Wf11 r� ��� 1 0 \ ` <br /> l` 5 w �liTY\ vv�Avli��i 5 wrmt'e �1J'csl stn vie-.2r-t <br /> W ot5}�A'\YY­ VOL CA lkY W111 tAgc <br /> 2e <br /> Inspection Form Included: p, ,t^ 8/5501 6 -y <br /> Comments Included: Q - 11 _ _ __ _ e <br /> _ _ 5 s 3-7o <br /> BusinesRe 'a Signal Phone Number I _ atu Phone Number j <br /> H4 �,� �.• , -e"IN 62081 <br /> INSTRUCTIONS ON BACK ?( IJ P L 1 2 3 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />