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jjWaste Tire Surve & Ins ection Re ort Inspection Report Numbery p P ■ <br /> CIWIWState f181(Nmla Survey Form - Page 1 1 1 - 1 0 0 6 6 9 8 <br /> CIWMB 181(New nage <br /> Califomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ?Yty C4> �fy 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J Inspected By Inspector <br /> Physical Address <br /> 113% lel NWY 9 9 <br /> ^� Inspection Date Q 1 5 O <br /> LOQ' C� Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> D0 PM 0 PM <br /> v. �qJ I nU <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) S- (Fill one only) (Fill all that apply)11 (Fill all that apply) (Fill all that apply), <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 1 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ®Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 11 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 1 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 1 Other: § 1 <br /> Comms P41-CDr �ic-�CJf ND- g (yv%g <br /> n✓IGC-t" , _ a— r----fie s F—. a -J A" t2-30-C`9') <br /> k._41z S 05- 003l 6 1 lc.,, / -7 D�?-77 2s e Til p <br /> nkArvMbr-r I's nD `- Oh r .s..!FL�g_ - ��r tiddLe�_` lD 0•-a.� i.^.-+y�'�s -1. <br /> 'Inspection Form Included:0 <br /> Comments Included:0 <br /> Business Rep's,Signature Phone Number Insp Sign u Phone Number <br /> t <br /> INSTRUCTIONS ON BACK E /4 M P L E 1 '2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0609004.0344 <br />