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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> ClWMf 81jNrnla Survey Form Page 1 1 4 - 1 0 2 8 7 4 <br /> CIWMB 1B1 thew nage <br /> California Integrated Waste Management Board <br /> Part A.-_Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: J O '� O ! r / Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ` � C$.f�11;� 10 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �/ Inspected By Inspector <br /> ,A40✓✓'► ' �Ot 2 C� _ 7� <br /> Phys ca Address 3 / U j Je.K4,4 L �t, <br /> 35-00 A 0-fo F/030,. Wlr <br /> y <br /> Inspection Date <br /> �r a 95.30 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) 5 (Fill one only) (Fill all that apply) (Fill a+l that apply) (Fill all that apply) <br /> f ® Active WPassenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 40 Indoor <br /> O i Q Inactive � Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> is New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body m 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 ENFORCEMENT STATUE_____-__.__-_-: <br /> r I IiAUI.11�4:ANt� �►NIP�:�T�tEQtJIf�BIVIENT� <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 NQtICd M:Ylolatton Q Extension <br /> Q Q i PRC§42953-Contracts with Registered Waste Tire Haulers. Corr plionce Deadline <br /> Q Q I PRC§42956-Registration/Decal in Vehicle m m I <br /> 0 ; Q �14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DAh Ell / <br /> I I I / mQ Q j 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I I I <br /> Q Q i 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days {Regliked for.NOV or l=M _ <br /> Q Q 114 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 ( 115� I(il8 t 8ntorcentsrtt <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities 1 ,r <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators10 x� <br /> Q Other: § - <br /> Comments Ttrja� PQ -IhS'Peef 1-ad� tb+y 7D Vi evj man Al ;t S A&k1j—eSt S V)'&V/ed <br /> f r l m P y-o_S etc f- �:00 J tov eKai ae5�s hr 3 �m,- ,s Ov►--Wf� - <br /> Inspection Form Included: Qr <br /> Comments Included: Q - - - C�- I "t bCJ i7�f tpr <br /> sl ass R 's Signature Phone Number Ins actor' S nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK �C�I'Ct�i�kt �1t + il � /1 I�� AP L <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />