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' Waste Tire Survey & Inspection Report p p <br /> hu Inspection Report Number <br /> Staleol 181(New Survey Form - Page 1 I - 1 0 0 6 7 7 6 <br /> CIWMB 181 aNew..g <br /> Ca111amIa Intepmted Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPIe, Typeone <br /> Site Suffix: 0RRoutine Re-inspection0 O Referral <br /> Observation <br /> LWW (1 r LL If Referral,choose referral type(Fill one) <br /> IdaflNfler a (itkV, O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name 0 — -- <br /> P`pj[�[� fry J� y���� Q) l� Inspected By Inspector <br /> �, <br /> Physical Address VV1I �( \J \/ rV 3 q 1 "JC.�'ti1.l. <br /> yaa5 �I PQp�� �1ac�e- <br /> Inspection Date / O / D <br /> c_Dc k'fb k, C495 a/5 Time In Time Out <br /> Business Rep Title O AM O AM <br /> ly 0 P 0 P <br /> Wc4 Operational Status Tire Type Business Role Storape Type <br /> Tire Count(Whole/PTE) r� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J 0 Active O Passenger O Generator O Outdoor <br /> O O Closed O Altered <br /> GPS Latitude O Hauler OIndoor <br /> O O Inactive O Truck <br /> Longitude – O Planned O OTR O End-Use O Container <br /> Business Type (FI all that appy) <br /> New The Dealer O Auto Repair Trucking Fleet O Government O Retreader 0 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 <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 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 /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § <br /> Comments Ro w*+K.- _`NI¢ <br /> Km's Wilson W r . kU aAd.... e to` - 4WW�l$rt'►t aQnid_ <br /> W Isf�l <br /> 'fjar. a T_r)✓DiCes ✓;e ed icor ser0ge— emits on sTk o,.rt "M&e24 viki heed <br /> i r --an S;+e— ,_&Vi_o4a� <br /> Inspection Form Included:O. / Q 2 <br /> Comments Included:O •! <br /> Business "AW' 31 nature Phone Number 1 ctor's n ure Phone Number <br /> INSTRUCTIONS ON BACK [EIXIAIM101LIE1 11 2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0600464.6116 <br />