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Waste Tire Su*eY p p& Inspection Report Inspection Report Number <br /> State C1WM 181(New survey Form - Page 1 1 9 1 0 9 4 7 9 0 <br /> CIWMB!8!(New 04.+04) ■ <br /> Callfornia Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 7, /p O _3 - 0 Routine O Re-inspection Q Referral Q Observation <br /> Local -C- �ti If Referral,choose referral type(Fill one) <br /> Identifier: ,_ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> or Facility Name <br /> Business <br /> L --�� inspected By Inspector <br /> Phys cal Aa c .11+61 ��-/-��2_ <br /> s� I �Nre'il/ L.J`�l S <br /> Inspection Date C) C) <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> A ' <br /> _ t..rr—tr-• <br /> 2�►^Ib Operational Status' Tire 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)j <br /> f ®Active I*Passenger ® Generator ® Outdoor <br /> Q Q Closed Q Altered <br /> GPS Latitude - Q Hauler + Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> I <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®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 ENN. R:0 ANT STATUS <br /> V - _ 14, 'NIZAN _ NO-i0E1,0115aM0*0 �fieiletIon EApinslon <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O <br /> DepPRC 42953-Contracts with Re istered Waste Tire Haulers. ol(ne <br /> Q Q PRC§42956-RegistrationlDecal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements �tq d d <br /> O O <br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB ' <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days d or NOV or- <br /> Q O 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 HaulersD10ra 41ft <br /> O O 14 CCR§ 1B461 -Manifest System Requirements for Waste Tire End-Use Facilities ll <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Comments „� /�� eq oAi/o, <br /> r! 4, 6 '` f <br /> k”) <br /> Inspection Form Include <br /> Comments Included: Q - I <br /> s nese Rep's Signature Phohe Number n or's Signature Phone Number <br /> /g g" MWWI <br /> 62081 <br /> INSTRUCTIONS ON BACK ' �9. , EoiX i�"'�lP L E Y 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />