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aWaste Tire Survey & Inspection Report Inspection Report Number ■ <br /> SCalifornia Survey Form - Page 1 1 3 - 1 0 1 3 6 3 9 <br /> CIWMB 181(New 04!04) <br /> Californiarnla Integratedgrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business.Profile Inspection Details <br /> TPID- Inspection p ' Inspection Type (Fill one) <br /> She Suffix: _ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local h Referral,choose referral type(Fill one) <br /> Identifier: �CHP 0CIWMB <br /> 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name — <br /> /_ Inspected By Inspector _ <br /> n/,07AZ1 J�//, <br /> Physical Address 3 9 / O / y //2041A, <br /> x370uaav�� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title <br /> I2- . 3 q- O AM fe AM <br /> J •PM �PM <br /> - — - Operational Status Tire Type �8..lne.BtR.I. Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (F(II all that apply (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B Inspection of Waste Tire Dealller,Generator,Hauler and End-Use Facility <br /> ...��..: ws .. ��Sirn+a .N .sic`'`� .1."�S�e,..�• t?:�:'w;.r', 'v�' �,,.., k��� ,, .;i`° �,ax?a `v... .!:. <br /> 0 0 1 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs Within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other. § <br /> Comments rs //v a_ 1 p <br /> le7'At-111:f <br /> Aa sLiu/e/e its, arc vrmt,,r K. �c�t���ruu.�oC , <br /> Foxe %ire d,,.O~ a� B GC,.r <br /> Inspection Form Included:0 / V18' <br /> Comments Included:0 Y <br /> Business Rep's Signature Phone Number Inspectoes signature Phone Number <br /> ■ INSTRUCTIONS ON BACK EiX a;M P L1E[ 11f213 62081 <br /> White Copy CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> n626304.0280 <br />