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aWaste Tire Survey & Inspection Report Inspection Report Number �. <br /> Stall of California Survey Form - Page 1 i 4 1 0 1 3 4 6 1 <br /> CIWMB 181(New 04104) <br /> Calltornla Inlet'rated Waate Management Board <br /> Part A•Survey <br /> Inspectlon Detail_s_ BLUE OR BLACK INK PEN <br /> Business Profile <br /> TPIO- p) O L/ / O O Inspection Type (Fill one) <br /> a"suffix: �r �r a Routine Q Re-inspection Q Referral Q Observation. <br /> IdLocal rI H Referral,choose referral type(Fill one) <br /> Idarttifler. . 4,1�.rL �,1^nom,f"1.6,(�Y'L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> �j <br /> Business or Facility Name <br /> Inspected By Inspector <br /> de' T-Kc3 - o ( rnK c�Z <br /> Physical'JAddr^ess <br /> S- "�ts�kn -- <br /> /\i Inspection Date 1 I I O /�. / 0 /� <br /> vi ��v/nr/L� Time In I Time Out <br /> 1p <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> -- Operational Status TinsTypr Business Role Storage Type <br /> T (Fill one only) EFlN W that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) r U <br /> ®Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q HaulerQ Indoor <br /> O <br /> Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> -- - - - — - - <br /> New Tire Dealer Q Auto Repair Trucking Fleet Q Govemment 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 Facilityda a <br /> ...„ - .;i�.,,, --^,�-�y—•— -.,:._ __ �. far v w;x, -."ty"� �,'s � 1 tfi3`"•'< .^`�, ��, <br /> 0 <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> t <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle a <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements e <br /> Q 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB m i <br /> Q 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q 0 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 HaulersN <br /> 0 Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> erators + t " <br /> 0 0 Other. <br /> (. ?. <br /> Comments, 1.. 5. (`�2 1 D!! _°l�s FLD� i W/ <br /> ''1l'f'u�c�- f�ar�-••Fo_✓ ��rc.gd. �?% ��_��a. �� _ `f�� �arvi� <br /> (3IM'[.a." Amnesty_J)my & 5ed o. E R' I_ee <br /> D d -. 3L4 N o <br /> Inspection Form'Included:Q <br /> Comments Included:Q r ys4. <br /> Business Re s Signature Phone Number ors Ig ature Phone Number <br /> ■ INSTRUCTIONS ON BACK IIEZAIMI-P'ME1 111213162081 <br /> White Copy CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0634704.0263 <br />