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t Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CFWMr181(NCalifomla Surve Form - Page 1 1 4 - 10 13 72 2 <br /> CNVMB 181(New nag4) y <br /> California Integrated Waste Management Board <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 2 1 7 ] Inspection Type (Fill one) <br /> Site Suffix: 13 / 1 $ - O ®Routine Q Re-inspection Q Referral Q Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: \\x/.(�./tA`- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -— <br /> Inspected By Inspector � <br /> �` 3 q <br /> Physy1 /vtC��, <br /> Address <br /> Ada/ ✓e <br /> /'(-/� <br /> I,(aA.fe n� / C,415330 <br /> 5 3 0 Inspection Date r <br /> ly_ / U Time In Time Out <br /> Business Rep Title O O O AM f z O0 AM <br /> 0 PM 0 PM <br /> �il! �rnsle y �Fa-�'v�rLl_.C' ( ✓ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) L9 j� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> D <br /> 0 Active ®Passenger *Generator *Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ®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 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 i <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 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 Q Other: § ,�{ / /� <br /> Comments gbtd-,,.,, [[ iwsi 1 Dr1 rL is � I VIQ TYJl(a1/J <br /> �ac,UIN IS bks -pie 67 'Qbl't�L& 4?s plus. ' Valli valLtC . <br /> 2P reamer-✓ire Pei r►meAVl)rn46t ` esfs vieuJed- NII <br /> _ <br /> J 101 ,i l�,.`ca.s. h-sc.cLrss.4d mani s sysim..-- �p� ------ <br /> Inspection Form Included:Q Gtl�) �f <br /> Comments Included:Q .!%i/(/�at;;;:D <br /> 1AL — LI�usIne s Phone Number I s cto Signature Phone Number <br /> p — <br /> J`p "` 62081 <br /> INSTRUCTIONS ON BACK i � �� �V i� y1� 511II1 'I) IEIX AI IPILIE1 1112131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 0609004.0333 <br />