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egg Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 { - Q-� <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection Detatls, <br /> TPID- ` - ® / Inspection Type (Fill one) <br /> Site Suffix: •/ Routine Re-inspection® O P Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identlfler: �0. � Q CHP Q CIWMB Q Complaint p Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> T� WQ l.©I�j`StiDri ►� <br /> Physlca Address 3' C1 - t d: <br /> .2nz, E gone -e Ave _ <br /> /foam f e-Ca, GF c/,33(,, Inspection Date Q 3 p <br /> Time In Time Out <br /> Business Rep Title t�I�, 0 AM 0 AM <br /> Domani(_ _cj6 1 P U.� fr O PM 0 PM <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 /> f' 0 Active <br /> O Passenger 9 Q Generator Q Outdoor <br /> GPS Latitude - O ®Closed Q Altered <br /> Q Hauler O Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all.that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part.B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q 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 <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip togs 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 <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O1 Other: § <br /> Comments '*j'l,.5 fiL LL�Lf Op-S not M�yl1�ze vjas -e <br /> _ r�v�- _ fi jiY'es . Wt-e <br /> U& ' nuded 15 _ ori f_e zl cap JDre s opS <br /> + Are i Ad _ .n►vi t,offLn e " -}z, <br /> e <br /> Inspection Form Included:Q=ssep <br /> //��,,Comments Included:Q i'f 9re(dnature Phone Number: : ctorj Si nature: Phone Number <br /> INSTRUCTIONS ON BACKX A P , 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA - ® ■ <br /> A?0:::104•A1„g <br />