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Waste Tire SAey & inspection Repor, Inspection Report Number <br /> State C)WM <br /> 181(Now <br /> Survey Form - Page 1 I 9 Q 4 8 2 <br /> CIWMB 187(New 041D4) ■ <br /> California Integrated Waste Management Board <br /> Part A- Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile f Inspection Details <br /> f <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 T' ` t� Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: o CHP o CIWMB o Complaint o Educational Visit o Other <br /> Business or Facility Name Inspected By Inspector <br /> Colin-W a- v o-,44 4?4„�5 , <br /> Physical Address l `a , �V-�v Cj-1�( OIX, <br /> ( Inspection Date <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> 0PM QPM <br /> t Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ^ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active 0 Passenger Q Generator 0 Outdoor <br /> ' O o Closed o Altered <br /> GPS Latitude o Hauler o Indoor <br /> O * Inactive o Truck <br /> Longitude — o Planned io OTR ++ o End Use I Q Container <br /> Business Type (Fill all that apply) <br /> o New Tire Dealer 0 Auto Repair o Trucking Fleet Q Government o Retreader o Dismantler o Tire Derived Fuel <br /> Q Used Tire Dealer o Auto Body o Car Dealer o Collection o Crumb Rubber <br /> o Service Station o Hauler o Agriculture o Shredder o Other <br /> Park B Inspection of Waste The Dealer Generator, Hauler and End Use Facility <br /> ;,..,.., .,-,-„-,�,;,�, :„. ,..�,.. _ ,> Y,, ,�, , , ,�, r /�fes✓,, <br /> ✓i, �k� if ,ii/� /r.�`// i i�.i% %x/f/i.t � �� /r G �„- i�.;/1 fr/-•�i�-;j i�i rii%.%�- <br /> ii <br /> 0 o PRC§42951 Waste Tire Hauler Registration and Transport of Tires / /mayiwi /f!�%�••;y"��i,1/ y <br /> o PRC 42953-Contracts with Registered Waste Tire i <br /> Haulers. --. J �' <br /> PRC§42956-Registration/Decal in Vehicle .��,�; �j/,",:� /l�' ✓,;, <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 daysi/. <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years -; ��," i / <br /> o C) 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers j <br /> 0 0 <br /> 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r <br /> 0 o Other; § \ / <br /> Comments D LJ <br /> w, 1 �`^^'- '-- 0\Jy <br /> - <br /> Inspection Form Included: o <br /> � <br /> Comments Included: Q <br /> usines Rep's Signature Phone Number Insp.- tor's Ignatu - - Phone Number <br /> 91o� T;, /zy�, M09:111 r62081 <br /> INSTRUCTIONS N BACK « [e;`: h�t F L 3 <br /> . White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br />