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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State Of California Survey Form - Page 1 ( 4 - 1006585 <br /> CIWMB 181(New OUO!) <br /> calNomia integrated waste Nsnagement Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspectlon Details <br /> TPID- Inspection_ O / Inspection Type (Fill one) <br /> Site Suffix: �-. (} 7 ( l ( S Routine 0 Reinspection 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 orrF�Facility <br /> aName Inspected By Inspector <br /> Ph ca0.Addre38 / � � l � ` ��C f.,pula <br /> Inspection Date A � / —5 <br /> 5 3 7 7 A 0 Q :,;Z- a <br /> Time In Time Out <br /> Business Rep D} Title 0' <br /> 0 AM <br /> fir- l rt �� I O 9 P 0 D 1� OPM <br /> — Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) I (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) S <br /> 1 ' 0 Active 0 Passenger 0 Generator �Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair •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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <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§16459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§16459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§16459.2.1-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§113460.2-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 /> 1010 Other: § ` \ ' , \ \ <br /> Comments sa Vv�y�P ®acY� '�T� ln, WISH' I k"S <br /> fir- �A1 <br /> -- e� y <br /> Inspection Form Included: 70113 <br /> Comments Comments Included: <br /> J _ o bb <br /> usiness FAW Signature Phone Number Inspecu Phone Number <br /> INSTRUCTIONS ON BACK 1ERAW-PPILIE! 1 Z D3 <br /> 62081 <br /> ■ WhRe Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0600404.0035 <br />