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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br />ClWMte of California - <br />CIWMB18asteManage Survey Form Page 1 <br />California Integrated Waste Management Board <br />'art A - Surrey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />s Suffix: l I 0 7{ y c- d 1 <br />Local (�,� <br />Identifier: Qt4,f` <br />Business or Facility Name ( 1 0 - <br />I rl Z <br />Physical Address <br />b.95 N. So,Cr am p , <br />Lod, CA �scyb <br />Business Rep Title , <br />M�tti0 a2 Ow "ir <br />Tire Count (Whole/PTE) r 5 <br />0 <br />GPS Latitude <br />O <br />Longitude - <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet <br />® Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Service Station Q Hauler Q Agriculture <br />Inspectlon Type (Fill one) <br />0 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />Inspection Date <br />4 / <br />/ O / <br />0 ' <br />Time In <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Time Out <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />OAM <br />Q <br />OAM <br />' <br />0 P <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 P <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />• Passenger <br />® Generator <br />® Outdoor <br />Q Closed <br />Q Altered <br />Q <br />Q <br />Q Inactive <br />Q Truck <br />Q Hauler <br />0 Indoor <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Government Q R-o-4er Q Dismantler Q 77 p <br />Q Collectio <br />Q Shredder <br />re erWed Fuel <br />n Q Crumb Rubber <br />Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Comments L)� ,• t ; , f � " 41%, ,S — r 0 IMQ <br />pP2�c _� oL�rV w���en s _S , 0r 'rMess CTI rya ' ,� <br />T_ �a �, <br />V ► wa dated I Wee. Ar-eZ, M Objl <br />Inspection Form Included: Q ` <br />Comments Included: Q _ _ j*9.��Qa 8-99 <br />_ Business Rep's ignature Phone Number I tor's i nature Phone Number <br />■ INSTRUCTIONS ON BACK - a( p E ]l2 3 62081 <br />White Copy. CIWMB Yellow Copy: Operator Pink Copy: LEA ® ■ <br />U711604.0132 <br />