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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StaWallste of 181(No <br /> Survey Form - Page 1 i 3 - 010504 <br /> Cgrate 181(New 0004) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j CA - Inspection Type (Fill one) <br /> Site Suffix: i 3 ✓ OL 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: TD(k Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - Inspected By Inspector <br /> Loorni,S F�P�D0 C e I tra <br /> Physical Address 361 - 1 O �QYI VI�C. � <br /> a Iv o u► ,� S+1 — - -- <br /> �� Inspection Date I '� J / <br /> sic � Time In Time Out <br /> Business Rep Title O AM O AM <br /> T^^nin p) h� - O PM O PM <br /> Q� - Operational Status Tire Type Business R <br /> Tire Count(WholelPTE) ole Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t Q Active 40 Passenger 4D Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D 6 Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q 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 ®Other , /1'►Dreol Oar <br /> ar F)Ieei <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility dl <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <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 Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 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 <br /> Q Q Other: § <br /> Comments W w d - dai-ar, reVe has -f; ` <br /> ail 7*ye ✓ice awq�e_ af W;Imyh wa,, Ilee afta ncz) -Ares d <br /> 0,4 r rCOt �% e OC eIDMa /2 a r lot� � <br /> s <br /> D ur Oh r+e- CD 1�'tQC ^l/ LS f11 A <br /> Inspection Form Included:Q <br /> Comments Included:Q qV3—y7Da <br /> B ne Rep's Signa re Phone Number spe or's gn n Phone Number <br /> INSTRUCTIONS ON BACK ( id 9 IEMAIMIPIL <br /> El 111213 620811 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 023504.0145 <br />