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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Staten,California Survey Form - Page 1 l - 1 0 13554 <br /> CIWMe 181(New 04104)Calilomla Integrated Waste NanagemeM Board <br /> Part.A.-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details J <br /> TPID- r f /_ O - O I Inspection Type (Fill one) <br /> Site Suffix: "� (Q Q Routine Q Re-inspection Q Referral ®Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier: SanOa kfn (51m 'Y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspector <br /> Inspected By <br /> aR Awh DIsn�anf-le�- _ <br /> Physical Address S9 l r Te"( <br /> 35,ja b. m 1wer Ave - - <br /> Sto(_p i)I (�1� Inspection Date p S / 06 <br /> �� J (J Time In Time Out <br /> Business Rep I Title Q AM Q AM <br /> M ate-0 �l A55ZSfautt O PM O PM <br /> Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply)I (Fill all that apply) <br /> t 0 Active ®Passenger O Generator la Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-use Q Container <br /> Buslness Type (Fill all that apply) <br /> Q New Tire Dealer 0-Aut.Repair Q Trucking Fleet Q Government Q Retreader 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 „y <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> w j li <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. I�Mf <br /> I <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date- v. <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 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 90 �;; <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities )i, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 'k <br /> Q Q Other: § <br /> Comments Deot obseir✓afian . Thseet iOr► -1` uS da cF ler aezl' <br /> -Aa k4lowi VAS poked : 76u5 a l,%hf �oe5 pat aM kI Aiso&e-G- WaSIV <br /> �-cre5 Used lir s d $_� uc ec@, Tr rp Yram Iger ' S" <br /> Inspection Form Included:Qi 1342- <br /> (J r <br /> Comments Included:Q- <br /> Business Rep's Signature PhoneNumber In ctor's S slurs Phone Number <br /> ■ INSTRUCTIONS ON BACK I EjXjAjAkj P I L E 1 2 3 62081 <br /> White Copy.CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br /> 0624904.0190 <br />