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LIQ Waste Tire SL.. ,iey & Inspection Repo, 16 Inspection Report Number <br /> Slate of Callfornia <br /> CIWMB 18e ) survey Form - Page 1 1 1 - 1 0 06319 <br /> California Integrated WastastManagement <br /> Waste Management Board <br /> Part A- Survey _ _ —BLUE OR BLACK INK PEN <br /> Business FOroffle -- --- - inspection Details - <br /> TPID- <br /> Site Suffix: 0 L S Inspection Type (Fill one) <br /> ! 3 I v r 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Business FacilQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> s oi Name - <br /> Facility � Inspected By Inspector <br /> Physical Address <br /> 3da8 0,6-0k'oe- T( - <br /> `�.}�, C Inspection Date D 2- 1.7 1 0 ,S <br /> I� J a �� Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> i C��A2-� ` C�tLt.�12v► <br /> --- - — - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> f (� Active Q Passenger (P Generator Q Outdoor <br /> 0 Q Closed Q Altered N� <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <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 /> 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 Other �� <br /> Part B Inspection.of Waste Tire Dealer, Generator Hauler and End-Use Facilityev <br /> rr:• ' `''''" '�'' <br /> y lnr, ^�.',f- *11A ,•r � <br /> 4Y`_ �,1/fi'-v.._ V/^r <br /> 19 <br /> Q Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires , %�/ <br /> f �%%i `%�'r��fjirr/ jam/'✓//r%i/�_� <br /> PRC 42953-Contracts with Registered Waste Tire Haulers, /i,�✓��/ %i <br /> PRC§42956-Registration/Deco!in Vehicle <br /> 0 <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 14 CCR§18459.1 a (b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days r' r.'/ .,, r %r-�,i/%✓i�` <br /> i%// //�•�/ „�%fes:iii; �/ii: <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ] <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 14 CCR§ 18461 -Manifest System Requirements for Waste Ike End-Use Facilities / %i%,i!�`,=./��r-✓-,������ <br /> O / '/ / flr�/i ✓//' / <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O <br /> Other: § • //�' /�f�✓/%�% ' <br /> _rte <br /> CommentshsiU�1 T'1RtSc� a�lD� _`f� �fOUJt_. �Q S no eCt': <br /> J <br /> a L�i� l sof _ ofM t2yde� ai ld f i)-gs "Wjc c400 Lik,/-. free FcirIA,” <br /> f�✓eS ---Se r�;� 1Q &o 1 j o1,e==oQ N a'ti by od t}cczt,c CS iN 4) 4u�- �F- -C_IiAcl dt <br /> N C- /�lA V� vip _ r Imes <br /> Inspection Form Included: Q <br /> Comments Included: <br /> _ In s p Signature Phone Number I pe tor's I nature _ Phone Number <br /> -- i/fir/ /i Ff✓i �l ra/ 62081 <br /> INSTRUCTIONS O BACK 7>r y y� �4--"' EW. p (� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />