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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate.re <br /> CIWMBfCalifornia Survey Form - Page 1 i 6 - 1 0 0 6 6 0 4 <br /> CIWMB 181 tew 04/84) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- D 1 I Inspection Type (Fill one) <br /> Suffix: 17 Q <br /> Site SuRoutine @ Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. O J (�fil &(A `( �[f 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name t� I <br /> Inspected By Inspector <br /> Gia f 'Dt Scovj"tit T r e, 2 <br /> Physical Address �J — / 1 � � RtLi Z <br /> IGC. S, SC1Ci-Gtme^_f S�, <br /> Lc, 'J <br /> C'+- <br /> Inspection Date a 1 0 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM a y 5 0 PM <br /> Bob fire.nc� �'�' - - - <br /> Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t 0 Active ®Passenger ®Generator ®Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler , 0 Indoor <br /> 0 0 Inactive ®Truck <br /> Longitude — 0 Planned ®OTR 0 End-use 0 Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer ®Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ®Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End Use Facility <br /> MIMI <br /> 0 0 PRC§42951 Waste Tire Hauler Registration and Transport of TiresbX <br /> 0 0, PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle _ <br /> .t <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 14 CCR§18459.1 a b c Tire Program ID Number from CIWMB r <br /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days �s• <br /> 0 .0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ; a <br /> 0 Or , <br /> 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators }5 <br /> 0 0. Other: § tr <br /> Comments E—I 1'IS�e Gf1 On -f-cu-'r da N a.c A ifle— 6,011 D'W ma W&S Y1C"1`ecQ Enteree <br /> X411 prx-yioViso/c_7z`on iSStfeS ilo-ye- hee Cleau-� KB <br /> AgMx 3m WQs4te - res on S? e_�, 5'D-uSed circ S racked-and <br /> S'ta CW 111 al- . M(uu.fzS+ ✓ieK12� � <br /> Inspection Form Included.0 <br /> Comments Included:0 - g �ZZ(a IA C1L <br /> - /l <br /> Busins ep1 s.SI nature Phone Numberaor1*(SF9nafure Phone Number <br /> INSTRUCTIONS ON BACK 4_ '� ER M P � E1 g 3 62081 <br /> _ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LFA ® ■ <br /> 052" 204. 1142 <br />