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09210050018 <br />Waste Tire Survey & Inspection Report . Inspection Report Number <br />-teu <br />11 C1WM 181 (New <br />Survey Form - Page 1 I 1 - 110 8 4 8 8 <br />CIWMB 181 (New 04104) Y <br />Califomla Integrated Waste Management Board , <br />van A - Survey t$LUt UK t5I_AGK INK PEN <br />Business. Profile Inspection Details <br />TPID - Inspection Type (Fill one) <br />Site Suffix: / I ! �j - 0 Routine 0 Re -inspection Referral ®Observation <br />Local <br />Identifier: <br />��, �y► <br />St✓l� �1� <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />If Referral, choose referral type (Fill one) <br />0 <br />`-�" v <br />0 <br />0 <br />0 CHP 0 CIWMB 0 Complaint <br />0 Educational Visit 0 Other <br />Business or Facility Name <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Inspected By <br />Inspector <br />1(_L s <br />Physical -Address S <br />I <br />- <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Oj t_�_.— c <br />` <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Street <br />0 <br />Inspection Date <br />0 <br />j� <br />l- <br />q �j <br />® <br />lJ <br />P Ccde <br />City Stat,, 21P Ccce <br />City <br />Business Rep Title <br />Time In <br />0 AM <br />J <br />Time Out I <br />J 0 AM <br />p� <br />( V Q PM <br />E[j4:F1C I e PM <br />- <br />-Operational Status <br />- Tire Type <br />Business Role <br />Storage Type <br />Tire COUnt (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that'apply) <br />® Active <br />0 Passenger <br />0 Generator <br />® Outdoor <br />GPS Latitude I , I <br />0 Closed <br />0 Altered <br />0 Hauler <br />0 Indoor <br />0 Inactive <br />® Truck <br />Lon itude I^� <br />9 - I . <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 -Auto Repair 0 Trucking Fleet <br />0 Government 0 Retreader 0 Dismantler <br />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 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CIW MB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />® <br />0 <br />Other: § Iy�R lit 4_Cbl-_4mriLe__D ari�A-_ANt&-OLA.`\M, <br />Comments <br />Form Included: <br />Comments Included: <br />PL 0 <br />Phone Number Intor's,51gnfture <br />'62081 <br />INSTRUCTIONS ON BACK C rrect: �'(ncorre t: E X M P L E 1 :2 3' <br />■ Whitepy. CI B Yellow Copy. Operator Pink Copy. LEA <br />