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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> i state of California <br /> CIWMB 181(N-04/04) Survey Form - Page 1 1 1 1 0 0 6 7 2 3 <br /> California Integrated Waste Management Board .. <br /> PartASurve BLUE_OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �Routine �Re-inspection QReferral <br /> Q Observation <br /> Low (7 MReferral,choose referral type(Fill one) <br /> Identifier. J Q/t- 4Z744,¢U4 3r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Cl/ p _ / / <br /> Physical Address 3 / D / S446,d 7t//,�Y� <br /> 974e� oo'/ - Inspection Date 9 C) 6 <br /> Time In / Time Out <br /> Business Rep Title 0 AM / 2 AM <br /> GLC L�4 iu-t r ( D O / O PM ( D J j J O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) e 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered �/! <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use 1 Q Container <br /> Business Type (Fill all that apply) <br /> Q 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 Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End Use Facility " <br /> ...._� • 1 x N -� gam' <br /> Q Q f PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q �kft cn. <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. � "F, "�` �• x. <br /> Q Q PRC§42956-Registration/Decal in Vehicle s h, <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1 a b c -Tire Program ID Number from CIWMB x <br /> � :.�. .. <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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q iQ 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities n <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other. § ------------ <br /> �r✓/� <br /> Comments d4lzd <br /> fir.` �Q ?ied 4a r �r�P . <br /> Inspection Form Included:Q .r �/ <br /> Comments Included: �`09�TL��'f3�� � `r Imo' - � <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK IEIXIAIMIPILIEI 111213162081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br /> 06212464,0069 <br />