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-: Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of Callfom(a AA <br /> CIWMB 181(New 04104) Survey Form - Page 1 1 6 1 0 0 6 3 0 0 <br /> califomia 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: 6 ^7 -7 5 t ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��N J014Ht� N ��I� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name dt� Inspected By Inspector <br /> �J ms'5h1„� <br /> Physical Address <br /> Inspection Date � n / / r] � 0 S <br /> ` G Time In 7 Time Out <br /> Business Rep Title O ASM Q AM <br /> r /, I 3 O ®PA11 L 2 ( 0 ®PM <br /> vac Fsun Ui /"r'wOperational Status Tire Type Business Role Storage Type <br /> TireCount(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 1 ®Active (®Passenger i Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> � Q Inactive �Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <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 /> Q 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 WastgqeeTire Dealers Generator,Hauler and End Use Facility s <br /> Y:' T+:' �Yy!cT :.#, �' K p� vF9Y.�.W�,''�.. •,'R'"f p' ' '4Xi.. <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle ' ) <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirementsk' <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q5 ' <br /> 14 CCR§18459:2.1-Submittal of Manifest.Forms and.Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers t ` <br /> 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§184.62-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q 1 Other: <br /> Comments �9girr•���",�' p ,ToS�O,�ag�et D �c.��$� �l r�_— <br /> �wC <br /> '18A In D L <br /> tot., <br /> 00-t Ch 4 - d <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> nes p' Phone Number Ins <br /> s Signature orts gn Phone Number . <br /> 62081 <br /> INSTRUCTIONS ON BACK '¢��t,��� cf XLAjEjXjAjA1k P1 1 ! 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> e529204.eO42 <br />