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[[rs Waste Tire Survey & Inspection Report Inspection Report Number ■ - <br /> stafaorcalr- Survey Form - Page 'I - 4 3 $ <br /> CIWMB 181(New 04/04) <br /> Callfomia Integnfed Wasb Management Board - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- n O ' Inspection Type (Fill one) <br /> Site Suffix: ' O (� 9 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ��j�� K Referral,choose referral type(Fill one) <br /> Ident�er: J`^ � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V -- <br /> Inspected By Inspector <br /> Tire <S S-fems G� - I O I <br /> Physical Address 3 J_e6 L( Zm_Z <br /> PaCk C Ak\t -,`goo — <br /> S�c�fi� Inspection Date O <br /> IVNt y 1, Time In / Time Ou✓t <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tim Type Business Role Storage Type <br /> The Count(Whole/PTE)- ^ . (Fill one only) (Fill alapply) (Fill all that apply) (Fill all that apply) <br /> ' r fJT *Active 0 Passenger ®Generator 0 Outdoor <br /> - - _ O 0 Closed 0 Alterod <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ®Truck <br /> Longitude — 1 0 Planned ®OTR ®End-Use 49 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government J1 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> service Station $Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> N' ,�,,:. <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires � C <br /> r � <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> I` <br /> O ; O n <br /> 0 0 1 PRC§42956-Registration/Decal in Vehicle + <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements rte' <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB _ <br /> 4 <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 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers fr <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 /> 0 0 Other: § <br /> Comments e aftelka0,3a's how <br /> ICLe xu etre ick lific t ( T s,hrctn�s P�- ceiV . <br /> ,nr�✓' <br /> t tau l q ,r rcvso lemr <br /> Inspection Form Included:0 <br /> Comments Included:0' IS <br /> �q-_sine s nature Phone Number Ins for nature Phone Number <br /> INSTRUCTIONS ON BACK X A P L 1 2 3 62061 <br /> . White Copy.CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br /> 0629804.0347 <br />