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t , Inspection Report Number <br /> Waste Tire SuNey & Inspection Report <br /> Slate of California <br /> CIWMa 181(New 04/04) Survey Form - Page 1 1 6 1 0 0 8006 <br /> California lntegrated waste Management Hoard <br /> Part A. Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID-- k — ! - /— Inspection Type (Fid one) <br /> Site Suffix: 1 d I j ! ® / • Routine 0 Re-inspection Q Referral Q Observation <br /> Local �+ If Referral,choose referral type(Fill one) <br /> Identifier: J �wh0 CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name <br /> 1.r► Inspected By Inspector <br /> Fre,l� C. A j¢osr� 1 y�4' _ <br /> Physical Address / / ! ( •.• arl ��IS <br /> 5w 0 taw /.Z- <br /> 6? <br /> Inspection Date Q Qr <br /> c�—A Time In Time Out t <br /> Business Rep Title J O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) <) (� l © (Fill one only) (Fill all that apply) (Fill all that apply) f (Fill all that apply) <br /> • Active Q Passenger 0 Generator 0 Outdoor <br /> o O Closed Q Altered ` <br /> GPS Latitude I Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned j Q OTR 0 End-Use 41 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler 0 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 4 <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility l ENFQR EC+I 4'f <br /> 7K— <br /> y A HAULING AND MANIFEST REQUIREMENTS Natlf;a Of Yhlattanxtfl� l4lt <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ;` <br /> PRC§42953-Contracts with Registered Waste Tire Haulers, lcsCgmpllr <br /> �?#n13ll1t�1 <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 DAtp ml l l J) <br /> l <br /> O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB ,( <br /> Q 1 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days .71 <br /> (Rog / <br /> 0 � 0 I ✓ // . r r/ice <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers pr . <br /> 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> � S <br /> 0 O Ali IM-i0 <br /> Other: <br /> Othe <br /> Comments <br /> 0�,�. LA}' (' Jrl-q, LJgy j Ma i-_ rSaa A&,"" 1310L�) <br /> �'—���►-x,..a--fav G� g (S � Irl --G ✓'7ar��tu-{�-�.� � �`�`� ""�Z,r s C�-1 <br /> Inspection Form Included: Q `;V <br /> Comments Included: 0 - - <br /> Business ep's S re Phone Number spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK }Cot�f�e MoIct: E°X A i',ft F �, t 62081 <br /> _ _ It <br /> White Copy: IWMB Yellow Copy.Operator Pink Copy:LEA <br />