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Waste Tire Survey & Inspection Report <br />Sfate of calflomia <br />omCIWMB 18IN— ) Survey Form - Page 1 <br />CalHla Integrated WastastManagmen <br />Waste Managet Board <br />Part A - Survey <br />Inspection Report Number ■ <br />9.1010749 <br />BLUE OR BLACK INK PEN <br />Business Profile Inspection Details. <br />TPID --7 <br />` 7 ' - 0 Inspection Type (Fill one) <br />Suffix: Site S(i) I (e Routine 0 Re -inspection 0 Referral 0 Observation <br />Local ( <br />Identifier: <br />Business or Facility Name 1 <br />7 ' ol0rL f �l <br />Physical Address <br />r2� q k <br />, �- 9S,-;L0S <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />Inspection Date 0 �r / I 0 / 0 <br />Time In VV Time Out <br />Business Rep <br />Title O AM O AM <br />#j&U^d bytj <br />O PM O PM <br />Operational Status Tire Type Business Role Storage Type <br />Tire Count (Whole/PTE) (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br />r 6 0 Active 0 Passenger 0 Generator 0 Outdoor <br />GPSLatitude ° 0 Closed 0 Altered 0 Hauler <br />0 Indoor <br />° 0 Inactive 0 Truck <br />Longitude - 0 Planned 0 OTR 0 End -Use 0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />® Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />0 0 i PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 0 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 0 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 0 Other: § �/ _y /+ �/ I <br />Comments PoulZ1tQ l•uS datet4 Rt il( / 1*s LC--Tf <br />f S IQ vol wi-e lUaS' e jVeDor �cry l Si>7� $- ei tcO11 1 io `LLfZ <br />iln �ttr?t„fr �t�o_C �� vlinP �r PCS sri �oi'Dt7vLw�nvtnt 7� Ih�,�i�l�/e_ i�in <br />0 Tire Derived Fuel <br />1 <br />Inspection Form Included: Q r <br />comments Included: Q, <br />Business Rep's91gnaturi <br />■INSTRUCTIONS ON BACK <br />0716504.0039 White coPY C1WMB <br />4 8743awe * <br />Phone Number I or' nature _ Phone Number <br />-�,�' - dA E X R P 1 23s2oe1 <br />Yellow Copy: operator Pink Copy: LEA <br />