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Waste Tire S4rey & Inspection Repo Inspection Report Number <br /> talo of California <br /> CSurvey Form - Page 1 I - 1 2 6 <br /> CIWMB 181(New 04.04) <br /> California Integrated Waste Management Board <br /> 96 <br /> Part A- Survey _ -_ - _ _ BLUE O_R_ BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: f f 5 a D O Routine ® Re-inspection Q Referral Q Observation <br /> Local �` If Referral,choose referral type(Fill one) <br /> Identifier: �Q F� ��r �-tYl 6}LAYt 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name CfJ/.. inspected By Inspector <br /> Physical Address 0 !'i 6't t— 9Qc4,Lz� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> Q PM O PM ' <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(W hole/PTE) O f(Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> V ® Active ® Passenger ® Generator it Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive ® Truck <br /> Longitude — 0 Planned ® OTR 0 End-Use Q Container J <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Is 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 /> Inspection of Waste Tire Dealer, rotor, Hauler and End Use Facility % <br /> Part B - Insp Ion Deal r Generator, Me <br /> m .. <br /> 1 1 �ui "POJf <br /> Q {' PRC§42951 -Waste Tire Hauler Registration and Transport of Tires „ r/. ', <br /> r <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 Q <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB s ' ER <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years /,/;'. ✓y%1 % y%� /- <br /> O 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators --- <br /> 0 <br /> -- <br /> Other: § /i ,• /�/ �/'j /�"%% <br /> Comments 7�e fnC t O ri r'{1 S( Gf ay CU,Ld --f't'1.Q- Av ll o w i v tq wa.5 ii 0 7i ," � 'Svj -7gk^e'S f h <br /> J L. � <br /> _ pur(,� _S�lctl(�Z. ✓QGt' sta`i� �! S1ZGS .._TZN. ►"2 � Sjq(a_ <br /> Vime—d _.4v— ulQs'tT_ tu'' I� LaA4c'hgo <br /> x' in o P 3D fS ..f° 0 ayt ;ftD vj 1K stv _- <br /> Inspection Form Included: Q V4_ <br /> Comments Included: QiBusiness Rep' Signature Phone Number _I ctor's S aturePhone Number <br /> �/ �• �-/,;,, �, — --62081 <br /> INSTRUCTIONS ON BACK Ir t =; l. t� L <br /> White Copy:CIWMB Yellow Copy:operator Pink Copy:LEA <br />