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r= Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Braised California Survey Form - Page 1 1 6 - 1 0 1 0 7 0 5 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK_ INK PEN <br /> Business Profits Inspection Details <br /> TPID- ' ^ j Inspection Type (Fill one) <br /> Site Suffix: CV) ®Routine Q Re-inspection 0 Referral O Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: V�'A'/• ,`JI Q CHP O CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility NameA <br /> Art-,skk VV Ye Inspected BY / ) Inspector <br /> Physical Address 23 J 1 1 D <br /> Sfi� CA Inspection Date D S / / O / O <br /> Time In Time Out / <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> 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) <br /> f l <br /> *Active ®Passenger ®Generator ®Outdoor <br /> O Closed O Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O IO Inactive ®Truck <br /> Longitude — 0 Planned O OTR O End-use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader ®Dismantler O Tire Derived Fuel <br /> O 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 /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> n1 <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ''* * - <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB s e y <br /> �.. <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days � � - .. <br /> Vl <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 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 $ r <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § '� § ti <br /> Comments -fYc� me' f �'S 6P7t ' A4 <br /> //3 al^e rack—etc��, Sfuc�e�(tidla l`� ^�s �. r s�,oa, u. CTL wlavii�ec�c <br /> ATO rYl �ur�.il(rt;.- ! I►�- �t S�p� tl i put oL� �r t�t10.5�� ..'"f CVS�Sa.Q S . �b <br /> Inspection Form Included:O 14W-2031 <br /> Comments Included:0 - <br /> �'guslnesslftep.s'signature Phone Number I e for s tura Phone Number <br /> INSTRUCTIONS ON BACK E P � 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0719304.0040 <br />