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08010040132 <br /> ■ Waste Tire Survey & Inspection Report. Inspection Report Number. ■ <br /> 919. <br /> State of Callfornla Survey Form - Page 1. ( 7 - 10 7 3 4 9 6 <br /> CIWM8181(New OI/04) <br /> califomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN. <br /> Business Profile Inspection Details <br /> TPID- I / J O I Inspection Type (Fill one) <br /> site suffix: b I ®Routine Q Re-inspection Q Referral Q Observation <br /> Localch�u / If Referral,choose referral type(Fill one) <br /> Identifier: S� to ,� /�'—..,.-`-1`'_Y Q.CHP Q CIWMB Q Complaint Q Educational Visit. Q Other <br /> Business or Facility Name - <br /> Gl Inspected By Inspector <br /> � I <br /> Physical Address - p <br /> St er et <br /> Inspection Date ' Z <br /> L 1kc Cn C_A �t.S_33 —J Time In Time Out <br /> City Jtate ZIP Code <br /> Business Rep Ti�t/l/e� F T]®PM m'm ®PM <br /> 0 A <br /> _ Operational Status Tire Type Business Role Storage Type .' <br /> The Count(Whole/PTE) .(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) _ <br /> ®Active Q Passenger ®Generator ®Outdoor <br /> Latitude H J. �O Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q Truck ^ <br /> Longitude - �� Q Planned ®OTR Q End-Use f '^.ontainer <br /> -�_ _LLEE <br /> Business Type (Fill all that apply) TtJr'4L - <br /> 1 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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility jW@11111 <br /> ENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q VtionQExtension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of TiresQ Q PRC§42953-Contracts with Registered Waste Tire Haulers. DeadlineQ Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements / m mQ Q14 CCR§18459.1-Tire Program ID Number from CIWMBQ Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 daysuiQ O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 yearsQ Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR.§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generatorsiance - No Violations <br /> Q Q Other: § <br /> Comments <br /> 6, - <br /> % �_—/ ✓tea r/� �,i-��i_S f _06_ew' _ <br /> —1��-1_fG_-!_2Y�—t�.E=1'-f• /� � �.�/_�R�}7��i_�Nd 1r10_�let/_'�_LS_. <br /> Inspection Form Included:O X <br /> Comments Included: <br /> Business Rep's ignature Phone Number t. <br /> 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> • Exar� P 't, E � 'zs <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />