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�, t�9259•��05�3 <br /> Waste Tire Survey Inspection Report Inspection Report Number <br /> State ClWM 181(Now <br /> Survey Form - Page 1 I 1 - 1141224 <br /> CIWMB 161(New na0ge) Y g <br /> Callfomia Integrated Waste Management Board `� <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> ' TPID- Inspection� Inspection Type (Fill one) <br /> Site Suffix: 515 1 6 6 p� <br /> D �� O � ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> yl _ Q CHP Q CIWMB Q Complaint Q Educational Visit. Q Other <br /> Business or FacilityName <br /> Inspected By Inspector <br /> PhysicalAddre <br /> V1c <br /> fJo 1 I 9 - 1 11 O 1 LL,411 <br /> Street <br /> Inspection Date <br /> L_�rxn— <br /> City State Zip Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> I/Eo� 5 1 ® PM .._ ® PM <br /> �e <br /> _ij.rb - <br /> Operational Status Tire Type - Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill.all that apply) <br /> Tire Count(Whole/PTE) <br /> :L5 10,�. ®Active ® Passenger 46 Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude I f i� Q Hauler Q Indoor <br /> J O Q Inactive Q Truck <br /> Longitude - h I , r I i I Q Planned Q OTR Q End-Use Q Container <br /> I ^' <br /> Business Type (Fill all that apply) <br /> Q New Tire,Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <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 I I <br /> Part B -Inspections of Waste Tire Dealer, Generator, Hauler and End-Use Facility vx <br /> w , _. ��.,. QNG ANDMANIFESTf ��.<,� Vi Iii�� � "Eztensio <br /> oa on kQ n <br /> Q Q PRC§42951-Waste Tire Hauler'Registration and Transport of Tires L; g w �i <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. +Comphane3�Deadlined� w., <br /> OO <br /> PRC§42956-Registration/Decal in Vehicle �„ $ <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m&/gym .mkt <br /> O O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB ° <br /> � . <br /> nit (Regwretl for/VOV Ot DCT) ' ` <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years ��„ � <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire HaulersQ^Referred h,CIWMB Enfdreement <br /> Q O 14 CCR§ 18461 -Manifest System Requirements for.Waste-Tire End-Use Facilities <br /> * , <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators � t � ,w ��,�• <br /> O n CompUance - No Viola <br /> Otions r <br /> Other: § ra " «)+ R <br /> Comments UV Cm !--S. <br /> � <br /> Inspection Form Included: Q 2 Q <br /> Comments Included: Q - = 3 eo�� &rv-6i- <br /> usiness <br /> O r9 ERep's Si natur Phone Number Insp ce Phone Number. <br /> c Jv — 62081 <br /> INSTRUCTIONS ON BACK Cor ect s Incorrect ( EWAIM P L1EI 11.12L3 <br /> White Copy: IWM Yellow Copy:Operator Pink Copy:LEA ® • <br />