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-�v✓8J�9J <br /> iii-M Waste Tire Survey & Inspection Report Inspection Report Number <br /> StatefCaCIWMO ( rnla Survey Form - Page 1 19 - 1025706 <br /> CIWMB 181 181(Now 04104) <br /> Cellfornla Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- l / Inspection Type (Fill one) <br /> Site Suffix: G ( / •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � hodVA?h ck'k � � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other a / <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address V f <br /> Inspection Date 6 2-7 "53 c <br /> Y ) Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> > > <br /> Active Q Passenger *Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Typo (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 19 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 /> ����jr. �jf <br /> Ili <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. rX, <br /> O Q PRC§42956-Registration/Decal in Vehicle T <br /> �1 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB - <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 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 J <br /> O • •14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators :rFir <br /> , <br /> Q Q Other: § i <br /> Comments �/ <br /> �SA / � <br /> ,Qy177xL 3w 1wc ` /,7per'f'o'r1 KQl�4l fel afQ?C. Ufa`at✓iv+�l,✓a- <br /> Ta cal� aq v'ot +�- W'4t vtlbe4M +n��.&��. )Vit ZAC.V-M_�f�. <br /> will t c �.-�'�G•n Gcf I I� �t i^ vv-i% ,VIA' _ VCr Lo w1 �Iq ut Ce . <br /> - - _. _. _- <br /> Inspection Form Included: Q f ]/ r� <br /> Comments Included: Q - ---- - - ` d,v <br /> Bus ssRep's-Signature Pho e_N_umber pe n Phone Number <br /> INSTRUCTIONS ON BACK �4LL.� k f 2 3 62081 <br /> ate; <br /> While Copy.CIWMB Yellow Copy:Operator Pink Copy:LCA <br />