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1 T <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> Slatted Cal nla Survey form - Page 1 12 - 1 01 3 1 7 5 <br /> C WMB 181(New 04/04) <br /> Cagfemla Integrated <br /> maM <br /> letl Waste ManegeBoard <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- inspection Inspection Type (Fill one) <br /> Site Suffix: / 3 7 / J 7 9 I <br /> Routine Q Re-Inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: I C'/0,2 C-//10t — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> /tet S S �/+t/iP�?4 <br /> Physical Address J / / o / -SllaA0-7'.ti!A- 1.4 <br /> Lri�ir-/y^� �s3 Inspection Date o 07 / 0 7 <br /> L? Time In Time Out <br /> Business Rep (� Title Q AM Q AM <br /> O PM - _ 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) (Fill all that apply) <br /> 1 d 0Active *Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> O I Q Inactive 0 Truck I <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> - I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0707PRC <br /> C§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q §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 /> 00 Other: § <br /> Comments <br /> 6ej'V /e.yr[r�«/ f'Y G Slj 7 /�y/('on �i_%r �J�'!C/o.cc�ew,.�.�J I etc�,)✓t <br /> -7; L 'J vi'a c✓c s[� v., ✓1e cc. /!/D o'er P►�7�'�, - <br /> Inspection Form Included:Q ./ <br /> Comments Included:Q <br /> �Ws ess Rep's Signature Phone Number Inspectors Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK r I l o u <br /> ��II� �I . ,. � IEIxIalhtlpjLlEl I112131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0708104.0047 <br />