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Ce Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stalest California Survey Form - Page 1 { 5 - 1 01 4 9 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ O I Inspection Type (Fill one) <br /> Site Suffix: q 7 0 Routine Q Re-inspection 0 Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> n Inspected By Inspector <br /> ! C{C�i'yLsL' Jctpr 147A�_;4 <br /> Physical Address / 3 - Q <br /> �' <br /> L I s�1B,80TA/i'�D .q <br /> 39i5r A/, Ul,,'ec clx ,L,e -- <br /> _9/-Vc4t'-r 9Sa res' Inspection Date 0 ,6 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 0 PM � 7 ,� y �PM <br /> - Operational Status Tire Type' Business Role Storage Type <br /> n <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> y <br /> r r Active Passenger i Generator 0 Outdoor <br /> O O Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 9 Truck <br /> Longitude - 0 Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q 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 /> O Service Station Q Hauler Q Agriculture Q Shredder I.Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> t <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires pl <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O Q. 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 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 /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire.End-Use Facilities - <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> c <br /> 0 O Other: <br /> Comments jh-.PAu-f�;7srf *`1, �Y ec{G� /J__ � i�O LU` f�6714 <br /> /:�2�"e""6 &&-_3 15 44,7Z /3as arc <br /> 06je.vewe_ 9 ��rti axee <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> B mess Reps s Signature Phone Number Inspectors Signature, Phone Number <br /> INSTRUCTIONS OACK on X Alrp ` 62081 <br /> INSTRUCTIONS <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy,LEA ® ■ <br /> 0615104.0430 <br />