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Waste Tire Sul. vey & Inspection Report Inspection Report NumberState of California <br /> im <br /> CIWMB asteManage Survey Form - Page 1 1 2 - 1 Q 1 7 4 3 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Sualnes Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q Routine O Re-inspection O Referral O Observation <br /> Local r-- If Referral,choose referral type(Fill one) <br /> Identifier: a (�t� kjiL t�f - O CHP Q CIWMB O Complaint O Educational Visit Q Other <br /> Business or Facility Name ` t1X Inspected By Inspector <br /> © <br /> Physical Address <br /> 93o E . cgA WQy <br /> SfDck tv il-i v! R'Ez06 Inspection Date 0 <br /> Time In v Time Out <br /> Business Rep Title 0 AM O AM <br /> 'Fbisz) l 1�'l.�c) 0 J.'K�- O PM O PM <br /> A7 <br /> Vv Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE)) Q� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> '/ O Active IS Passenger 0 Generator o Outdoor <br /> O 1 ® Closed O Altered <br /> Latitude <br /> GPS , O Hauler O Indoor <br /> o G Inactive O Truck <br /> Longitude - O Planned i 0OTR O End-Use O Container <br /> I <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader jr Dismantler O Tire Derived fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENNFQ.RCEMENT:STAT. " t' <br /> .y HAULING'AND-MANIFEST REQUIREMENTS <br /> O O O NO,C"s-Of vlolattlon <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires i i y f ;..M. <br /> O O i PRC§42953-Contracts with Registered Waste Tire Haulers. compile Deadline <br /> O O 1 PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> /r <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O I O <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days {R044M., <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ¢ <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> V W- <br /> O O < <br /> 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators '` •�` f� • - <br /> O O other: g ; <br /> j` L . <br /> Comments .T-msPeG�,a� UI AC;_ Qfd GDA versa-tion (.JA 0Wk1,9r V�_pLle-CLU <br /> P10 VUCLSt-4 -kfP--S CtTl 7r cat + . '1iTeS Yen?p✓ed ,nowt V 2k�5 ctahP <br /> SeA+ W A Scr op Owelt�o(e s, 4 per ca-r-j re-e ytd e- ►'Vt t?LQ skv-etdees. <br /> WpsiY fil-e i�For maf%iim dt:Sf-l'bt�-e_c� ahci oti.SC�css Na via 12;h0"7s-, <br /> Inspection Form Included: O — j} - &8_q9//_ <br /> Comments Included: Q a 7f(J(p <br /> ss Rep' Signature Phone Number pector' S nature Phone Number <br /> _ 62081 <br /> ao - a 1IXabPINSTRUC71 ��ACK �Co- -1 n <br /> dEJ I Y Z 3 <br /> KB White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />