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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Elt <br /> 11 <br /> State W.B1aldomla Surve Form - Pa e 1 6 - 1 0 1 0 7 6 6 <br /> CIWMB 181 teManage y <br /> California Integrated Waste Management board <br /> Part A-Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details .. <br /> TPID- 1 S 5 / �j _ O I Inspection Type (Fill one) <br /> Site Suffix: Q �(7 O 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: &1v `TjUG�,t�(� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name JVD <br /> Inspected By Inspector <br /> Physical Address J t/ <br /> 5 y0 A/, Sco- f-`s Ave . <br /> '5-ILC _�oC� Inspection Date�ISa03 v 1 <br /> Time In Time Out <br /> Business Reap'1 Title O AM 0 AM <br /> X e 1 �l � �I A 0.410. Q�✓� 0 PM 0 PM <br /> fOperational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ®Active ®Passenger •Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®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 (6 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 Tut T✓i,4_4:�)eef <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> a <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements k. <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB ,, <br /> r <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days < ; <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q f4 CCR§18461-Manifest System Requirements for Waste Tire End-Use facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> u� <br /> a <br /> Q 1 Q 1 Oth r: § )a. � <br /> Comments iCiu�tYv, On `S Glu Q. I/ndl Jos Yl0 S <br /> �C <br /> uyS WjAq6f for 4ire, ,�,,r ;C2 view/ <br /> fi <br /> )� v+V re Y or ' ih r vrrol�iv),S <br /> Inspection Form Included:Q <br /> Comments Included:Q— - - <br /> Business Rep's Signature Phone Number I ct gnature phone Number <br /> INSTRUCTIONS ON BACK ��IE!!XIAIMIPILIE1I 62081 <br /> ■ 0716504.0114 While Copy CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br />