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eee_ <br />Waste Tire Sui0y & Inspection Repo Inspection ReportNumber ■ <br />8eH State of California 7,1 - 10884 31 <br />iC Cgrated Waste <br />eManag) Survey Form - Page 1 <br />California Integrated Waste Management Board <br />Par+ A.. Cttrvav' BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />- <br />TPID - <br />Site Suffix: <br />D <br />/ e I -/ 7 _ <br />JJ <br />[Ell <br />Inspection Type (Fill one) <br />(a Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />Local. <br />Identifier:. <br />J <br />r� <br />0 CHP 0 CIWMB 0 Complaint <br />0 Educational Visit 0 Other <br />Business or Facility Name V <br />i <br />Inspected By Inspector <br />3 O <br />Physical Addres <br />a� �. /_t� <br />, <br />Inspection Date <br />Street / � Q f� <br />56 � " ` 5.2y <br />[_v <br />f <br />V <br />I <br />Time In <br />0 00 AM <br />Time Out <br />nn 0 AM <br />VI� I / ®PM <br />Citi StaLa ZIP Code <br />Business Rep Title <br />Lvi Svlck <br />t�l'j� iI®PM <br />I <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />1 ' <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />0 Closed <br />® Passenger <br />0 Altered <br />® Generator <br />0 Hauler <br />0 Outdoor <br />0 Indoor <br />O <br />GPS Latitude <br />0 Inactive <br />® Truck <br />Longitude - <br />I <br />0 Planned <br />(6 OTR <br />0 End -Use <br />® Container <br />Business Type (Fill all that apply) <br />® New Tire Dealer 0 Auto Repair <br />0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />® Used Tire Dealer 0 Auto Body <br />0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler <br />0 Agriculture 0 Shredder 0 Other L <br />I <br />Part B - Inspection of Waste Tire Dealer, Generator,. Hauler and End -Use Facility <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 0 14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 0 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 0• 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />010 Other: § <br />Comments V <br />L4 6,8/0- <br />76jr 4 <br />.� n _v. <br />Inspection Form Included: 0 <br />Comments Included: 0 - <br />Business Rep's Signature Phone Number. Inspecto <br />® INSTRUCTIONS ON BACKoT'rr'e' - : Inc''or ect: J E JX J A JMJ P [ L j <br />White C py: CIW Yellow Copy: Operator Pink Copy: LEA <br />Phone Number <br />62081. <br />