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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> B, State of 81(Now S u rve Form - Page 1. 1 4 - 10 0 6 49 4 <br /> CIWMe 181(Nem nage Y <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLU_E OR BLACK INK_PEN <br /> Business Profile J Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L 3 7 0 Routine O Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB Q Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> P�hlslcal Addressc <br /> /17 V J Vko dleX' — •Imo— 1 <br /> V Inspection Date O <br /> Time In Time Out <br /> Business Rep Title C7 2 Q AM Q AM <br /> \ ` ^QPM QPM <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 /> 1 JP Active O Passenger a Generator Q Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler tO Indoor <br /> O O Inactive 40 Truck <br /> Longitude _ 0 Planned O OTR O End-Use Q Container <br /> Business Type (Fill all thatapply) <br /> 0 New Tire Dealer O Auto Repair ,Trucking Fleet tO Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler 0 Agriculture O Shredder O Other <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> ir v:',,. ..- 'R...."..- „m c Yt;Yui ' fir. '� r-i �+' <br /> �, � + $ F <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. r o <br /> PRC§42956-Registration/Decal in Vehicle •s.: <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ;• <br /> 14 CCR§18459.1 a b c -Tire Program ID Number from CIWMB + a <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire.Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 yearss� r <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators10 1 t <br /> O Other: § <br /> Comments <br /> re <br /> m.A s� e, N o �v r a 144 �'C Ltsvlcgr+i. <br /> ntered <br /> Inspection Form Included:Q1 y f <br /> Comments Included:Qi0 a31 7� /s "'16f8 <br /> Business Rep's Signature • phone Number :phone Nuihber <br /> 62081 <br /> INSTRUCTIONS ON BACK ;'X r� l� .. 14 MF 1. E Z121 <br /> ■ White Copy.CIW MB Yellow Copy:Operator Pink Copy.LEA ■ <br /> f_752a2a•4. 1185 <br />