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Waste Tire Su ny & Inspection Repor. . Inspection Report Number <br />�> ato <br />S - <br />ted alltornla Survey Form - Page 1 1 4 1 0 1 4 8 0 8 <br />CIWMB 181 New 041041 <br />Celllornia Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -/ Inspection Type (Fill one) <br />6 Site Suffix: ?j 3 -:2, Routine Q Re -inspection Q Referral Q Observation <br />Local <br />Identifier: <br />Business or Facility Name <br />PhysicLlddress <br />Business Rep <br />Tire Count (Whole/PTE) <br />GpS Latitude <br />Longitude - <br />�;_5 ;),q o <br />Title <br />0 <br />U <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 />l/ 2Y7)LA� <br />Inspection Date v 1 / 06 <br />( 6>-5 <br />Time In <br />A 1NIT�- 4, <br />Time Out <br />j- <br />,' MA_ WNG )A` IFE>�RECtJIREMENT8 ,- <br />Q Nf tftt <br />0 AM <br />Q <br />O AM <br />' <br />O PM <br />' <br />O PM <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 />0 Active <br />• Passenger <br />* Generator <br />• Outdoor <br />Q Closed <br />Q Altered <br />' <br />Q <br />O 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />* Truck <br />Q Planned <br />Q OTR <br />O End -Use <br />Q Container <br />Busineos Type (Fill all that apply) <br />+� New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <br />® 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 />Q Dismantler Q Tire Derived Fuel <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility ENFORC <br />A 1NIT�- 4, <br />V-1 <br />j- <br />,' MA_ WNG )A` IFE>�RECtJIREMENT8 ,- <br />Q Nf tftt <br />a <br />iftt <br />Q <br />O PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />' <br />O <br />O PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Gonlplifuj <br />r , <br />PRC § 42956 - Registration/Decal in Vehicle <br />' <br />Q <br />O 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />ppb <br />f <br />i <br />O <br />o 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />r <br />O <br />O 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Q <br />O ' 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />O 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />.: <br />�^ <br />14 CCR § 18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />r, M <br />O <br />O Other: - <br />- asf'' <br />' ii''% %✓�// j. <br />Comments " d <br />NaW,v tis or -'cas <br />�_CL C%\ A- C CAAS �S <br />ct,Gt 1l 1� +A, <br />Inspection Form Included: Q <br />Comments Included: Q <br />- <br />Business Rep's Signature Phone Number pec <br />Phone Number <br />INSTRUCTIONS ON BACK _ R.M P L E„ <br />_ ,... <br />hits Copy. CIWMB Yellow Copy: Operator Pink Copy: LEA <br />62081 <br />1 3 <br />& <br />z4 <br />