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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ofCaBom7a <br /> CNVMB 181(New 04104) Survey Form - Page•1 - f -3 - 10063 7 8 <br /> California Intogratod em <br /> Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPI,D- Q Inspection Type (Fill one) <br /> Site s1,fnX ( z 4 9 I s l o Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one)' <br /> Identifier: 4��� �� � 0 CHP 0 CIWMB 0 Complaint :0 Educational Visit 0 Other <br /> Business or Facility Name •../ -- <br /> Inspected By Inspector <br /> Physical Address 3 R <br /> - <br /> /'��� Inspection Date © � � 2 Z <br /> Time In Time Out <br /> Business Rep Title *0 <br /> AM + 00 AM <br /> Z � QPM ` 7i D j 400PM <br /> Operational Status Tire Type ' Business Role Storage Type <br /> Tire Count(Whole/PTE) -7 cc> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active •Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> u,�psLatitude O Hauler Q Indoor <br /> t� O 0 inactive 0 Truck . <br /> Longitude - 0 Planned 0 OTR 0 End-Use ®Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler �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-Inspecction 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-ReglstrationlDecal In Vehicle <br /> 0 0 14 CCR§IB459 -Responsible Entitles Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-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 41 14 CCR§18460.2-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 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § <br /> Comments <br /> c►u.aQ -�''f++Gs .a.-� C1�r.5olyd�fit' �'... �1�.-cy `J3 oe !larg A,o.ox7 <br /> �jl-7©D G.�as-1� -�t�4'i✓s a �s.-� -I S p Q i .,..� l.c,v�fo.-/+ ,,,�.le F..j <br /> Inspection Form Included:0 <br /> Comments Included: <br /> RInBusin ' Phone Number <br /> INSTRUCTIONS ON BACK 'E N1 M P i. 62081 <br /> ■ White Copy.CIWMB Yellow Crary:Operator Pink Copy LEA ® . <br /> 0529204.0022 <br />