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E= Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CIWMf181(Ne <br /> Survey Form - Page 1 7 - 1 0 1 3 6 2 6 <br /> CONMB 781 stew 04/04) <br /> CalHomla Integrated Waste Management Board <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspectlon Malls <br /> TPID- inspection- fy � Inspection TypeQQ Q(Fill one) <br /> Site Suffix: 3 0 V^ 3 ! V 0 Routine Re-inspection Referral Observation <br /> Local If Referral,choose referral type one) <br /> Identifier. �1L. �(it,�,i h i Q CHP Q CIWMB Q Complaint <br /> laint Q Educational Visit Q Other <br /> Business or Facility Name V0 <br /> �^ Inspector <br /> GInspected By InspG; e6&"'_Cla—le- Z. <br /> Physical Address <br /> Inspection Date O � / / � / � .,(c?'G -"tel C!•,,Sl, v <br /> Time In Time Out <br /> Business Rep Title Q AM AM <br /> O 19 O PM D O PM <br /> V Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> !Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 9 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 Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> ME <br /> Q O 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 �: ��a•� ,. <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements y <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMBh F sc <br /> Q Q 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 Tri Logs for 3 ears <br /> § P 9 Y <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 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 /> Q Q Other: § <br /> Comments Aae-I&ji4y 4w4 Aklel Olt' W_ ,J_ 94r" allze <br /> i ' vt'�wld rt x- 7S' <br /> Ll/4yfP �+/ of <br /> - �:•'/-fn"��k,C �.� �fGus-��= /moo r,b��.�S�,-, . <br /> Inspection Form Included:Q <br /> Comments Included:Q .� �by Z,gal-Qg4r S(lot3 ¢T �� y�pa <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK AAS P 1112131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> -1-1'-604.0093 <br />