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Waste Tire Sway & Inspection Repori0 inspection Report Number <br /> tE; StateCalifornia SForm - Page 1 19 - 1008009 <br /> CIwMB181(New <br /> Callfornla Integrated Waste Management Board Survey <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> BusinessProfile inspection Details <br /> TPID- Inspection Type (Fill one) <br /> S'ste Suffix: �! l( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �� 1 If Referral,choose referral type(Fill one) <br /> Identifier: `Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Namm e //y <br /> Inspected By Inspector <br /> -iq tn1fJM¢...� ' <br /> Physical Ad I f� <br /> (� ! C/ ` <br /> /SIS' <br /> Uc;lla�o c �- <br /> yInspection Date D / <br /> rvrlc�Fr' CA ?52,31 l <br /> Time In Time Out <br /> Business Rep Title 0AM AM <br /> A,,,-a <br /> / ee, 0 PM 0 PM <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)l <br /> t ° ® Active 0 Passenger ® Generator Q Outdoor <br /> C Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O 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 O Other . -- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility j EN PQ <br /> HAULING AND---MAN -Bar REQUIREMENT$ <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires , <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. f Caf�p111t <br /> O Q PRC§42956-Registration/Decal in Vehicle ^" u <br /> Q : O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Qgtq <br /> Q O : 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 14 CCR§18459.2,1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip g Y Logs for 3 ears <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O . O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators /''/ r✓ <br /> Other: <br /> _ / j� � Jam,. /_ L _ <br /> Comments (' y t�1C�.r`ct7C,l ( —! t�–�L+5`fG �'f iresi <br /> ci, re, <br /> v` l/�^QC7fl1� Gt(/k;-i'_- `" ��-G �Rc._ <br /> Inspection Form Included: Q L <br /> Comments Included: Q <br /> i Bu meas Rep's Signature Phone Number Ins ctoes Signa ure Phone Number <br /> { <br /> INSTRUCTIONS ON BACK f - '� E' A.01 F L 712:N 62081 <br /> WkAe Copy. PJVMB ellow Copy.Qperator Pink Copy:LEA <br />