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Ili <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r Slate of California <br /> CIWMa 181(New 04104) Survey Form - Page 1 - Q <br /> California Intrted Waste Management Board <br /> Part A-Surve _ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection D etalls. <br /> TPID- � � � � � � - O � Inspection Type (Fill one) <br /> Site Suffix: ,l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: �s'11i O�QQ/��_"jy �IsGss Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Le <br /> Inspected By Inspector <br /> Cod''e'-,, j!✓t _ � off•- <br /> Physical Address 9 l / J l�r3/3-V JYffs✓jj <br /> Inspection Date Q O oZ 07 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> PM O PM <br /> v Operational Status Tire Typp e Business Role Storage Type <br /> Tire Count(Whole/PTE) 0 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � <br /> 9 1 •Active 0 Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> D Q Inactive Q Truck <br /> Longitude - O 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 O Crumb Rubber <br /> O Service Station O Hauler Q Agriculture Q Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q 0. PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <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 Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 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 Generators <br /> Q 1 Q 1 Other: § <br /> Comments _1,4 GA, <br /> W� �.� ' �aa.'-G%'�r! �/ Lam+ /.'?�'c 6y,�yl� �Co /'.r�o✓.e W�tsr<< <br /> '✓�! 9�i^'s Y;,e.�.roP <br /> 3 �!/o ✓,�.�-►tires--.-� <br /> Inspection Form Included:Q, �o 7 <br /> Comments Included:Q �� <br /> Buslrt iss Rep's ure Phone Number Inspector's Signature - Phone Number <br /> INSTRUCTIONS ON BACK V, d Et}( Af M P L 1 2 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 0705904.0325 <br />