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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CrRM x181(Nmia Survey Form - Page 1 1 5 - 01 3 5 fi fi <br /> CIWMB 181(New Wlo4) <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A•Survey _ <br /> Business Profile Inspection Details <br /> TPID. F 1 j. O (� 3 11 % Kn. eclion Type (Fill one) <br /> I Site Suffix: I `-f 4 _( v outine Q Re-inspection �Referral Q Observation <br /> Local /`_ ferral,choose referral type(Fill one) <br /> Identifier: c�/9A�iArry Q CHP Q CIWMB (16 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 4` g � 3q l 1 � - �% z <br /> Physical Addr s <br /> 510 N' ukckon &4e <br /> Src ltfon G^ `?920 <br /> C Inspection Date 0 "7 / 2 <br /> Time In Time Out <br /> Busines.sCCRep Title 1 I n'� 0 AM 0 AM <br /> li—N� 1' " flue ow - _ 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> y� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> 1 r 0 Q Active ,Passenger o Generator o Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q NJew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer •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 <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§16459 -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 /> CommentsWix f n, i" -0 ond!,cW I Vt.S <br /> Ala� 11_916-S kL UYA uhr, aco <br /> �Zo� Dy <br /> - )6 5., c Ut -fin <br /> r r aQ c ` 'cccs Rd e ' <br /> Inspection Form Included: MA <br /> Comments Included:Q 4. �'r�I � 1'100 � <br /> uslness Rep's Signature Phone Number Ins ctor's i atura Phone Number <br /> INSTRUCTIONS ON BACK E X M P EI 111213 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0622804.0436 <br />