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Le , Waste Tire Survey & Inspection Report Inspection Report Number <br /> State Cfwf'4 Kalifornia SForm - Page 1 i 7 - Q 1 3 0 8 9 <br /> CONMB 581(New 04184) Y <br /> CalHomk Integrated Waste Management Board Survey <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' 3 O X o �f� ' 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �L If Referral,choose referral type(Fill one) <br /> Identifier: SaK V oa c(ZK Nk K41 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> O cu Inspected By Inspector <br /> Physical Address <br /> $ao S. GAF V <br /> Lod; <br /> , Q dl�•tCF � / , Inspection Dale <br /> L <br /> ~l- (`^ jY Time In Time Out <br /> Business Rep r I J� (.Title Q AM O AM <br /> aLqV' V �� WI l� Q PM O PM <br /> ✓IS <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger to Generator 0 Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O 0 Inactive t®Truck I <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other SC,Da I Fit <br /> r'^ .. ,. ,... war.' g `�`' ,.._,.'�?•�,�°z�`.o l i ,.fE <br /> Part B Inspection of Waste Tire Dealer Generator, Hauler and End-Use Facility $ F � <br /> 0 Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> r <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 4 <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB � <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers _ <I <br /> 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 a <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: <br /> Comments j7 0- 1h ` I a <br /> �. Dry ti eFLOf <br /> r, TL'S �e o violati`o e <br /> Inspection Form Included:0 7 <br /> Comments Included:0 - ` <br /> Busl ss ep's Signatu a Phone Number I p or's i nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK jEjXjAjMjPji_jEj 111213 <br /> ■ White Copy:CIWMt3 Yellow Copy Operator Pink Copy:LEA ■ <br /> 0705904. 133'1 <br />