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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rrr <br /> state of California <br /> CIWMB 181 IN**84/04) Survey Form - Page 1;r-C­-j p - Q 1 1 <br /> C';,;la Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detal <br /> TPID- Inspection—7 Inspection Type (Fill one) <br /> Site Suffli O Q (V / 3 0 I Q Routine ®Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 Q CHP O CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name -- <br /> Inspected By Inspector <br /> PNOLMoll <br /> Physical Address �j 3 9 — 1 0 <br /> c) Waa)9v a- <br /> Inspection Date <br /> c t rY�/YI Time In Time Out <br /> Business Rep Title 0 / c O AM O AM <br /> C.rmevi iQo_ u h �jOn$�e 0 IA/{� `� •PM a ' 3 D 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (FIR all that apply) <br /> r O ID Active Q Passenger 0 Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive I&Truck Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair *,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 O Hauler Q Agriculture Q Shredder —Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 7Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q 1 PRC§42956-Registration/Decal in Vehicle <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 <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 Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q 1 Other. § / <br /> Comments TCe'Ir\s Oo)'\ I►� f�l , dWL 1 U,S C�( <br /> is `lY�tc --'le2t, Ylf W4st;t -trrcrs were hrudkd /IA i' <br /> Ili <br /> ra4ligm OCTL vlewt.-d bisCussed -fz rax- ' <br /> F 1tDtr +ir I f'. No1 QS Dr C 1'7C1✓AS_. <br /> Inspection Form Included:Q lV2� — ZDA 9/- <br /> Comments Included:Q "" —��53 ��" " w(o <br /> 13usine�gr u Phone Number Ins ctoes 1 nature Phone Number <br /> EA <br /> INSTRUCTIONS ON BACK ® X SIA P L S 1 2 3 62081 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0601=104.0018 <br />