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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of rr,la Survey Form - Page 1 1 4 - 100659 3 <br /> CMB181(N <br /> IWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> - / Inspection Type (Fill one) <br /> Site Suffix: G O *Routine Q Re-inspection Q Referral Q Observation <br /> Local (� If Referral,choose referral type(Fill one) <br /> Identifier: Jay,- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name O Inspected By Inspector <br /> 76 S Ti r�r-1�� 3 _ /14,f* y <br /> Physical Address A-, <br /> Q 9 / ..SaAAV <br /> 40 7.2,0 .S' A,,, <br /> f, 9533 Inspection Date © ' / 02 l Q <br /> Time In Time Out <br /> Business <br /> JRep � Title 0 AM <br /> / O / O PM 2 •AM <br /> 0 PT/4LC� D L�1Z� �Sp� [ - -- 0P <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) (Fill all that apply) <br /> 0 Active Q Passenger Q Generator Q Outdoor <br /> 0 <br /> Latitude Q Closed Q Altered <br /> GPS Q Inactive Q Truck Q Hauler Q Indoor <br /> 0 <br /> Longitude — Q Planned 1 Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair !Trucking Fleet Q Government Q Retreader Q DismantlerQ 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q 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 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 CIWMBi <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 yearsw.'>1 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers t�� c <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 : Q Other: § 1 <br /> Comments F�Lcss of e,/v �L �/ L!< I��• f�zl 1�,. <br /> /`�� u/ �7e� aftc lcc,Ot��� �e,c F:etc ufc � <br /> 3 �r. <br /> Inspection Form Included:Q <br /> Comments Included:Q A- iw,.r �f� "` <br /> Business Rep's Signature Phone N ber Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK 1EIXIAIMIPILIEI 1112131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ■ <br /> 0628404.0066 <br />