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09049040344 <br />Waste Tire Survey & Inspection. Report . Inspection Report Number ■ <br />I1 - 1088358 <br />State of Callforrlla <br />Califomla lnt"mtadiWasteeManagement Board Survey Form 04) -Page 1 <br />Part e _ c„r•.,e., RI IIF AR RI ACK INK PFN <br />Business Profile <br />Q <br />Inspection Details <br />Q <br />TPID - <br />Site Suffix: <br />I <br />Is <br />1z <br />� <br />Q <br />^ <br />(/ <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />I - <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Inspection Type (Fill one) <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />IS Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Local`� <br />Identifier: <br />uI ! <br />5a�, `oun � <br />1 Other: <br />Comments D _ D _ 1 t _ _L_ 1 _ .. _ It - r <br />�j q <br />Q CHP Q CIWMB Q Complaint <br />Q Educational Visit Q Other <br />Business or Facility Name <br />06 co ' \ <br />Inspected 8y Inspector <br />1 - O I <br />Ln SL <br />Physical Address <br />(a-010 <br />3ys <br />Street <br />Inspection Date o / <br />/ Fo <br />L5_�0L� -o <br />A 15adD <br />Crty <br />Business Rep <br />iI <br />State ZIP Code <br />Title <br />Time In _ <br />AM <br />Time Out <br />�Q <br />e AM <br />1 <br />1 ui�k gedOf(/� <br />O O PM <br />i i-- <br />0 PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />-� <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that -apply) <br />.-(Fill all that apply) <br />(Fill all that apply) <br />IS Active <br />I Q Closed <br />10 Passenger <br />Q Altered <br />4P Generator <br />S Outdoor <br />O <br />GPS Latitude <br />Q Hauler <br />i♦ Indoor' <br />Q Inactive <br />Q Truck <br />Longitude - <br />i ,'; <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Q Trucking Fleet Q Government Q Retreader 40 Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture Q Shredder Q Other I <br />I <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q. <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />1 Q <br />1 Other: <br />Comments D _ D _ 1 t _ _L_ 1 _ .. _ It - r <br />A <br />lion Form Included: (j <br />Comments Included: Ql <br />I Business <br />INSTRUCTIONS ON BACK Correct: Incorrect: fv X A M P <br />■ L E 1 2 3 <br />White Copy CIWMB Yellow Copy. Operator Pink Copy. LEA <br />Phone Nu <br />62081 <br />■ <br />