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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stale ClWM 191(Now <br /> Survey dorm Page 1 I - 0 2 7 6 <br /> CWYMB 181(New 04104) � <br /> California Integrated Waste Management Board <br /> Part A-Survey_.. _._ _ _ _BLUEO_R BLACK INK PEN <br /> Business Proflle _ + Inspection Details <br /> • TPID- Inspection� � 5 � � - { Inspection Type (Fill one) <br /> _J <br /> Site Suffix: ` ` • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> (y/� � tJ����- r�ce�. Inspected By 1 Inspector <br /> Physical ddress �K (� ) Cj t 1 <br /> /Iz 110 <br /> A. <br /> �'-' Inspection Date <br /> Time In Time Out <br /> !Business Rep Title O AM O AM <br /> / O PM O PM <br /> •Operational Status The 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 /> ®Active If Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler � Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned i Q OTR Q End-Use f Q Container <br /> L <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 Q Other <br /> Dealer, Generator Hauler and End Use Facility <br /> Part B Inspection of Waste Tire De e y <br /> W.A -;/. '..,l'x �y1% t4!..N >r7 % iiF i i,-.% i `r�/i� ,✓:fr ����ys !�' �.i';�.vz%�y" �` <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q I Q PRC 42953-Contracts with <br /> § Registered Waste Tire Haulers. <br /> PRC§42956-RegistrationlDecai in Vehicle �,�,/•"�„� -•:�� %"•' "'�• 'x�� <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> ''�' �iii- •!%��•,/.'•., ��%.i: ,"�"'%tel-'f <br /> Q Q 14 CCR§1B459.3-Retentionof Manifest Forms and Tire Trip Logs for 3 years ;'�.• �?' / <br /> is <br /> ' � Vii% �/�� / � "'�• <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q 0 14 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 ' %i% NIjRE; <br /> Q 1 Q Other: <br /> Comments <br /> tai f�-!G'���fa3S �1erof L <br /> Inspection Form Included:O,�� u 7 5- Z6 <br /> U C) <br /> Comments Included: - - - - - -- — -- <br /> Business s Igna ur Phone Number 7w ou __ I • Phone Number <br /> INSTRUCTIONS ON BACK �< �OJw ': - ' P 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy,LEA <br />