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Inspection Report Number <br /> Waste Tire Survey & Inspection ReportState ■ <br /> C1WM 181jornia Survey Form - Page 1 1 1 - 1 0 0 $ 0 7 5 <br /> CIWMB 181 New 04104) Y <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 7 3 - r Q Routine 0 Re-inspection Q Referral Q Observation <br /> i <br /> Local <br /> If Referral,choose referral type(Fill one) <br /> dentlfier: �G W, �KN.-�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 5-0 <br /> Physicfil Address <br /> L00 EE- <br /> C� Inspection Date /n. <br /> Time In LJ CCC��� Time Out7 T <br /> Business Rep Title O AM O AM <br /> QPM 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> 0 Active 0 Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 4D Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container �4 <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 f=acility EN FQR9EM�IJT`.�T T�� <br /> V °A HAULINQ AND MANIFEST REQUIREMENTS <br /> 1 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires `NRfiGe Qf YIAIQt)Qtf (� ttirl�lo�r <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. CompUp)Yt€e E�R�lI) <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Data: <br /> Q 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR 18459.2.1 -Submittal of Manifest Forms and Tire Trip Los within 90 days (RBcI!ldQ/ iDy�J / <br /> 14 CCR§18459.3-Retention of Manifest Farms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements far Registered Waste Tire Haulers IplrjirldJ1jrf;}1 �/ <br /> 0 0 p, <br /> 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End Use Facilities <br /> 0 ✓ r/%/iv / ✓ /� /Y//Jr%i //iJ <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> J <br /> O O Mull <br /> /�. <br /> Other: § <br /> - Comments �{ila✓Ti,y �Ar..tS ln�%�yrt-� � t�lrX�C �lY�.� vL�./C37,i.� !�ZtrS <br /> cidAt q4^�Q ! TlnlLiY- rx�Ic,�r�.. s'7��-s v,•. ��� G l��cr+� <br /> �Lc9 y>,ty"�' ji1aVG� �-:9"�'� '-t"%r-�- a�..��,r �''�15-{'tr+^�i�,—... • Ja'`� .. <br /> Inspection Form included: Q �es <br /> Comments Included: ��� 'vIs Rep's 9-17 u e Phone Number ctor's Signa ure Phone Number <br /> INSTRUCTIONS ON BACK I_ Cf' -I fit, 62081 <br /> I� I� II �I ��fflTl <br /> White Cop :CIW M Yellow Copy:Operator Pink Copy:LEA <br />