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Waste Tire Survey & Inspection Report Inspection Report Number <br /> state CIWMB <br /> of 81(New Survey Form - Page 1 l 2 - 10 0 6 3 2 8 <br /> CI'NMB 181(New 04!04) <br /> California Integrated Waste Management Board <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> rl3usiness Profile Inspection Details <br /> TP)D- c� / J — Inspection Type (Fill one) <br /> Site Suffix: 3 p z �j f Q Routine ® Re-inspection Q Referral Q Observation + <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier; �� h/� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 <br /> Inspeetegd,By I Inspector <br /> Physical Address �gr� jge{ifs <br /> iInspection Date 0 6 I I <br /> Time In Time Out i <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Gir. f�U_Y h h �� I - - --- Type- -- <br /> Operational Status Tire Type Business Role I Storage <br /> Tire Count(Whole/PTE) I(Fill one only) + (Fill all that apply) (Fill all that apply) (F(ff all that apply) <br /> I ®Active + `'Passenger *Generator Q Outdoor O Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> O + of...five I Q Truck <br /> Longitude — — _ I Q Planned Q OTR ' i O End-Use ® Container <br /> Business Type (Fill all that apply) III <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel I <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> *Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> I <br /> Part B -Inspection of Waste Tire Deafer, Generator, Hauler and End-Use Facility � <br /> //N. <br /> r //���N, %% i/moi,!/: /i. '�,�. _ n.�..M 1✓�I�� /��1TfG�Lk AI _ / .��.'9"y° /�/•C^w/�/y -:/�r����i <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953 Contracts with Registered Waste The Haulers./ <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 114 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 years <br /> '% ./�//ice// �f /' �j/✓ <br /> 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other. § <br /> Comments —r'Pt G![1T� _I S T�S�I rP►r <br /> — ..r---//t<.. �_/,l D.l �-r`.tf��''/f .-�t( 111%1.",t J.��'"`:s� _�,��/ 7 -• r�N.. � <br /> Inspectlon Form Included:Q j <br /> — — - - , -Z 9 0U <br /> + <br /> Comments Included: O Business Rep's Signatur Phone Number _ In c s Si na a Phone Number j <br /> . r <br /> INSTR6;6W09 ON BACK y y z 62081 <br /> KB White Copy:CIWMB Yellow Copy.Operator Pdnk Copy LLP,, <br /> Lo <br /> �, <br />