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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> t State of California <br /> CWMB 181(New 04104) Survey Form - Page 1 ( - 10 10 0 18 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- o5 r) ' Inspection Type (Fill one) <br /> Site Suffix: &Routine Q Re-inspection Q Referral Q Observation <br /> Local H Referral,choose referral type(Fill one) <br /> IdIdentifier: G-.+/IIA` V QC�/A1 jI Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 1000 ( - <br /> 6emc(�/ /+ _ 04 `% S,23 <br /> % S,23 ' Inspection Date <br /> (V�~/ Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> _Dade Porf e r I r ucl-'1Q� "f— 0 PM - - -- 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> jP Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive @ Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) —- - <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 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 ®Other �3�I f y1/d T(a,�r"4 1v"r <br /> Part B Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility '. <br /> I k3 - ' <br /> »s�-�� 5�.Rl4JGit'.�' � ._ ,.�,... ..�r�ti.... . .{.g �t� •err <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires tttl <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. ` <br /> Q O PRC§42956-Registration/Decal in Vehicle w <br /> O O + ,.. ,; <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ` <br /> Q O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB a <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q le 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 /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 1 O 1 Other: § <br /> Comments Q i`7Ae nz 1 ied; -H.' .Suses <br /> .uXtS�' Q r iTe l AY�e t yr 4�1' �7-1 <br /> fir I" <br /> all' f mfe— indoi us VipAl <br /> Inspection Form Included:Q <br /> Comments Included:Q -r �& r <br /> _ Busines9 R 's Signature Phone Number Inspect 's g tore: Phone Number <br /> i� 62081 <br /> ■ INSTRUCTIONS ON BACK1. <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LF1t <br /> ® ■ <br /> A7A"-;1Ci4.n097 <br />