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U'; Waste Tire SulaY & Ins orL Inspection Report Number <br /> 11 <br /> Inspection Re p <br /> State California Survey Form Page 1 i 3 - 2 ? 7 4 <br /> CIWMBB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> _ i <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l p y 0 1 �f 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 Name Inspected By Inspector. <br /> t!\"r\., V 6-� <br /> Physical Address 3 "1 - If <br /> 1 -)-6 a \/ Itl�b"A .�\� <br /> A lt-� 15 3 Inspection Date (' 6 / Q 6 I 0 <br /> G!f Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply). <br /> © Active Q Passenger 4P Generator 40 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler i Q Indoor <br /> O Q Inactive Q Truck i <br /> Longitude Q Planned Q OTR O End-Use 1 Q Container <br /> Business Type (Fill all that apply) <br /> 10 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEM NT_STATUS <br /> A - HAI .iN MAItFEST:ICkIIREMENTS Q Ngtics tat Iotatlon Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O i PRC§42953-Contracts with Registered Waste Tire Haulers. CQmpll`6cmidline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program (D Number from CIWMB I 1 1 <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (lfiea d.fAr NU.V ArEXTJ <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers is InfOrceIT10[tt <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities y _ <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O � O � r� ��► t��! utatlMti9t+t <br /> O O <br /> ,Other: § r/'% "' - — J <br /> Comments � /_�� �I r� �• , L�,�,1f_ t L4 <br /> Tolr-A/i ` 7 VVl.%As'A' o VXj6 S 4 WaS�C_4%Vles Q1 re- /rt d 01,%A.A VA4U WJ <br /> Inspection Form Included: Q <br /> Comments Included: Q. � <br /> Business ep-s Si ure Phone Number <br /> ;Ins is Si ure Phone Number <br /> s 62081 <br /> INSTRUCTIONS ON BACK Lprret, � (nIfi P`l� f i 3� <br /> Entered <br /> KB White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />