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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State o,nla Survey Form - Page 1 C - 1 01 4 $ 0 0 <br /> CIMB 181 181(New 04104) <br /> Callfornla Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TP)D- y Inspection Typo (Fill one) <br /> Site Suffix: I Z Z� q b �p p I* Routine Q Re-inspection Q Referral Q Observation <br /> LocalY� If Referral,choose referral type(Fill one) <br /> Identifier: �Rr � ,� � -�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other ± <br /> Business or Facility Name fly j <br /> 1 _ �� Inspected By inspector I <br /> ��>� �11n�k- Leo.5ih <br /> Physical Address 3 i 3 9 - � t`� � �otrFe� 4►J'`t�-K 5' <br /> Inspection Date 5 <br /> Time In Time Out <br /> Business Rep Title I - O AM O AM <br /> O PM O PM <br /> �A� L cL\I k �i e.� <br /> �.✓�5 � �,� ( <br /> Operational Status Tire Type Business Role � Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply)` <br /> f ® Active Q Passenger ® Generator Q Outdoor <br /> I <br /> Q Closed Q Altered f <br /> G � <br /> Latitude Q <br /> D Q Inactive i ®Truck Hauler ® Indoor <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> I <br /> Business Type (Fill all that apply) <br /> Q Now Tire Dealer Q Auto Repair . Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel I <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> J Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End Use f=acility �'$TAi"uo <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> #�sslX�ln =_ nsrolr. <br /> �� �, <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. R - <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB % r < <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire I-rip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> I 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire HaulersO O <br /> O O <br /> 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities �• :% �-- �- <br /> O . 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O Q 1 Other: § <br /> Comments All <br /> 1_ , 4e,. 4- t,_aJ "71✓ --s /CSA v f v\t o/r- of r-y-j — <br /> . �,►�,,�._. -�Le- k a"Ier— 6CKA L� 4511SPY d r --��- <br /> ► - r'SP <br /> Inspection Form Included: O <br /> Comments Included:Q - - - - - -- - Z9 T4 <br /> Busines op s Signature phne Number Inspe r' Sfgnat re Phone Number <br /> i I�RI R 3 62081 <br /> INSTRUCTIONS ON BACK <br /> : , <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />