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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br />�r State of California <br />C1WMB 181 I New"""t) Survey Form - Page 1 12 1 01 31 8 3 <br />California Integrated Waste Management Board <br />Part A - Survey_-_ BLUE OR BLACK INK PEN <br />Business Profile inspection Details <br />Site - O D .S - ® / Inspection TypeQ(Fill one) Q Q <br />Site Suffix: 9 ® Routine Re -ins ection Referral Observation <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 Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />Q <br />P <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Local <br />Identifier: CLfL OQ�iGcrlr <br />If Referral, choose referral type (Fill one) <br />Q <br />Q CHP Q CIWMB Q Complaint <br />Q Educational Visit Q Other <br />Business or Facility Name <br />]27L'��7v rr AY,!�p /P�!' cr'�l '4-%r <br />Inspected By <br />Inspector <br />� <br />cJ <br />Physical Address <br />�j - / 0 <br />(fJ <br />Q <br />3-239 S <br />Q <br />Inspection Date <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Time In <br />Time Out <br />Business Rep Title <br />0 AM <br />0 AM <br />Q <br />O PM <br />0 PM <br />- - -- - -- - - <br />Operational Status Tire Type <br />Business Role Storage Type <br />Tire Count (Whole/PTE) 310 <br />(Fill one only) (Fill all that apply) <br />(Fill all that apply) (Fill all that apply) <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />• Active IS Passenger <br />If Generator Q Outdoor <br />O <br />! Q Closed Q Altered <br />GPS Latitude <br />Q Inactive Q Truck <br />Q Hauler ® Indoor <br />O <br />Longitude - <br />Q Planned Q OTR <br />Q End -Use Q Container <br />Business Type (Fill all that apply) <br />6,A <br />^ <br />C / <br />QI New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ® Dismantler <br />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 Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />Q <br />I 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 />i <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 />CommentsOF <br />sJ' <br />/ a <br />6,A <br />^ <br />C / <br />'Inspection FormIncluded: U <br />Comments Included: Q <br />Business Rep's Sig at <br />■ INSTRUCTIONS ON BACK I= <br />White Copy: CIWMB <br />0710204. 02E12 <br />Yellow Copy: Operator <br />Pink Copy: LEA <br />Phone Number J <br />62081 <br />® ■ <br />