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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of Callfornla <br /> ClWMB astaeManage Survey Form - Page 1 1 7 - 1 0 2 5 6 9 3 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details ' <br /> e' <br /> + TPID- 7 Inspection Type (Fill one) <br /> iSite Suffix: 3 - i (P Routine Q Re-inspection Q Referral Q Observation <br /> ` Local I If Referral,choose referral type(Fill one) <br /> Identifier: Sem, �TDCL tin C �, IQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `Inspected By Inspector <br /> Physical Adat � � <br /> Address I 3 - 1 e`,,,,, , u� <br /> 3S) � Nevi-+ali Rd - ` <br /> ` Inspection Date f� <br /> I �-ra�h V, CA- 9 Sa 15 V <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> �Ol; Q (1- �J( V1Ce. �R1�Q1� O PM O PM <br /> J C/ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply)I (Fitt all that apply) (Fill all that apply) <br /> t ®Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude , Q Hauler Q Indoor <br /> O I Q Inactive � Q Truck I' <br /> Longitude - Q End-Use Q Container <br /> Q Planned 0 OTR <br /> Business Type (Fill a))that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> II Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauter Q Agriculture Q Shredder ® Other E(p,/1mQyl+ Dga le-,— <br /> Part <br /> erPart B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility kNFgRCE99NT$TATO$__-__._ <br /> j <br /> _Ist HAISI�INQ f�ig1>�fF T:R IR M hI $ b Notto41of-Violation Q Extension <br /> Q , Q 1 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 I � � C�gmpll,»uce 0eadllrie <br /> Q O PRC§42956-Registration/Decal in Vehicle I <br /> Q I O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirementsq, m <br /> 0 Q1 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q I Q 114 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 daysfI {Requ(redlOrNQVgrEXTj <br /> Q Q `14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ` Q I440-rfd t.6101MM Atiforcoment <br /> Q Q 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities r I <br /> 14 CCR 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r % ✓�� r <br /> Q Q 4 § qs �l� " (viol;tAnr ` <br /> Q O Other: <br /> Comments <br /> bbt�l�. rQetx�-! � 1,(se `f�'e- lta�ler �rawno� 7;re {b �r�cl was�� <br /> (de c5-Oq a�Oprox , ���l��j two /Mc 'GrS� .4 Iso haul f�obcaf <br /> 4Yac,k9 r small _TrGcfors, -' (eax 20 -&,-cks (Wa0e ) on Please <br /> re+m,n on site -6r <br /> Inspection Form Included: Q ,, LAI, QG� <br /> fComments included: Q - - - � AOL <br /> j (((Business Re ignat re Phone Number 11poc�Wrign-t ure Phone Number <br /> INSTRUCTIONS ON BACK k C r : �.�{� I:P"I � ! 3� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />