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Waste Tire Survey A Inspection Report Inspection Report Number ■ <br /> a�rr State of California A <br /> CIWMB 181(No.04104) 0 4 6 7 <br /> California hrtegraled Waste Management Board Survey,Form -- Page 1 I o - <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - <br /> TPID- Inspection Type (Fill one). <br /> Site Suffix; 'Q Routine Q Re-Inspection 0 Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: Sam UID SCJ(�(,(,Y� � 'f1 Q CHP Q CIWMB ®Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 'Dowlels TIC- ('� _ <br /> S <br /> Physical Address 3 —I I I tu RtMZ <br /> r� n Inspection Date C)cj / <br /> Time In Time Out <br /> Business Rep Title7 ®AM 10 AM <br /> TO v� bahi �1 S ®W YIYi►� D 9 ` O PM V 3 D Q PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ) S Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' Q Active ®Passenger. p Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _. Q Planned Q 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 ya.r& <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility € \J <br /> M' '. <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires ate <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle ¢ <br /> Q Q 14 CCR§18459 —Responsible Entities Complying with Manifesting Requirements 'x <br /> Q Q <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 � sk <br /> Q .Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilitiess <br /> Q Q . 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators { <br /> Q 0. Other. § <br /> d <br /> Comments ZnStxc.- 0 n JW►R S ".114 1A)C S jy►ifi a-rtd bu cow►p lalyit *C0 G1oa33 <br /> mac+ a sn itune atorMt, ja P doeaLtau( 6�.hind a Sfiar�fr�on't res tw�tKh, <br /> -�nPpy yytr dQ?rMjVIeaQ -Fa_ 62 oy?,r Sao u6wt OA& wasfe f4r si> ed- <br /> Inspection Form Included:Q ^A y 1� - �/ <br /> Comments Included:® ✓ Al hS� /2j h5— ��t� <br /> Business Rep's Signature Phone Number In�,,wr, rePhone.Number <br /> INSTRUCTIONS ON BACK a4 rrlii � �X AA P $ 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0529204.0023 <br />