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aWaste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CIWME 181(omla Survey Form - Page 1 ( 9 - 1 01 3 41 3 <br /> CIWMB 181(Naw 04/04) <br /> CalHor r Intagnlae Waate Management Board BLUE OR BLACK INK PEN <br /> Part A-Survey____ BLUE. <br /> Business Profile Inspection Details <br /> TPID- /� Inspection Type (Fill one) <br /> Site Suffix: ` 3 I $ 8 V 0 Routine Q Re-inspection O Referral Q Observation <br /> Local c If Referral,choose referral type(Fill one) <br /> Identifier: VQ��(� �,( 0-01� O CHP Q CIWMB o Complaint Q Educational Visit Q Other <br /> Busines <br /> s or Facility Name Inspected By Inspector <br /> PhysIre/<83-I'l T✓""�-�- 3 G� - I o 1 <br /> Yoicp M, d- - <br /> Inspection Date I a- / O 9 Q s <br /> v ' I Time In Time Out <br /> Business ryReep1�� (�J Q Title D/� I AM 0 AM <br /> V <br /> }n((-(�-/�••rV i eiro I r� 1 !Pi� O o 0 PM I t / 5 Q PM <br /> _—/ Operational Status Tire Type Business Role Storage Type <br /> Tire✓✓✓Count(Whole/PTE) / (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> r ° I 9 Active Q Passenger 0 Generator Q Outdoor <br /> 0 O Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> 0 0 Inactive A Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Buslness Type (Fill all that apply) _ <br /> New Tire Dealer O Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O 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 /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-RegistraGon/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q p 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> OQ 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 Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 I Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 i o Other. § <br /> Comments kDkjjktC, j►'1 to ao n I•w �ut i I�4 ���Q �'� W QS no-ted 54 t4� <br /> ( Mc,Czv <br /> Aseb a r j4�P�2c( haul�•-�r��r� r -lo S,Zirvi�.G �rttcic �1e2{'. �hvoi <br /> aid d _PkwfQCopitl -frpye hew o &5MLffa was&*e- k. ._ ' <br /> list wags S an i T r e✓ <br /> _S_ <br /> Inspection Form Included:Q <br /> Comments Included:Q - <br /> Busir/e�-'-Jsa Rep's SI nature Phone Number I for S ature _ Phone Number <br /> INSTRUCTIONS ON BACK LIE1 111-21362081 <br /> ■ White Copy!CIWMB Yellow Copy.Operator Pink Copy LEA ® ■ <br /> 0600604.0188 <br />