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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State ofWasCalifornla Survey Form - Page 1 1 9 - 1 0 2 5 6 0 7 <br /> CIWMB 181(New 04104) <br /> Calffornta IntegragratededWaste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� Z � � � � Inspection Type (Fill one) <br /> Site Suffix: tD Routine • Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: h G7�c!N�^ -�y ��� Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name tr / Inspected By Inspector <br /> U-we-rs <br /> �Grt��aGTL•rJr`�J � / r <br /> 'Phys a Address <br /> Inspection Date Q L� © / / S7 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 1 I <br /> i! l � O PM O PM <br /> / n C-/`�J"'r v <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fitt all that apply) I (Fill all that apply)' <br /> ' 0 Active Q Passenger S Generator Q Outdoor <br /> O Q Closed ®Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O O Inactive ®Truck <br /> Longitude - O Planned Q OTR 9 End-Use Q Container <br /> Busl ness Type (Fill all that apply) <br /> O 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENfQR EMENT_STATUS.,. <br /> .... --- <br /> � ' <br /> i :_= HAULING ANP-MANIFEST REQUIREMENTS::,-' <br /> _ <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires NOthae.0} Violation O Extension Q PRC§42953-Contracts with Registered Waste Tire Haulers. COmpI10" Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 1 § ( )( )( > g T <br /> 14 CCR 18459.1 a b c -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§16459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days ;(RepuAvd.forNQV orE)M <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - -'�-- <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Ma Rntortaernent <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> • Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O Q Other: § �,Ort �tlimpllr�lt�e • � VL41Mtlorts :-. <br /> Comments <br /> ir-- ( r i —� •-F�r- G ���-� "7�fres -�"�.�- Grp v�e�..,�.e�Q �..-_ <br /> Inspection Form Included: <br /> Comments Included: 0 <br /> 'I Business Rep's Signature hone Numb�er� or Ign Phone Number <br /> INSTRUCTIONS ON BACK ty 3( A Ihh F L i„': 62081 <br /> While Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA KB <br />