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09049040014 <br />tIl- <br />Waste Tire Survey & Inspection Report Inspection Report Number <br />State Is crNM 181(N.. Serve Form - Page 1 I1 - .1088347 <br />CIWMB 18, (New nage ' y <br />- Callfomle Integrated Waste Management Board <br />Part A - Curvcv' RI IIF AR RI ACI( INK DFN <br />Business Profile <br />0 I <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Inspection Details <br />0 <br />TPID - <br />Site Suffix: <br />1 <br />I 1 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />^ <br />9 <br />' <br />0 <br />O <br />I <br />0 <br />Inspection Type (Fill one) <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n <br />® Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />Local <br />Identifier: <br />'r <br />S JQ0.�uln COU4 <br />q� <br />0 CHP 0 CIWMB 0 Complaint <br />0 Educational Visit 0 Other <br />Business or Facility Name <br />I M t is Aub D Sman�l�� <br />Inspected By Inspector <br />Physical Address <br />a ate N co <br />Street <br />Inspection Date <br />Q <br />I_5iackjo—r\ <br />cit- <br />115 ""(�q I <br />City <br />Business Rep <br />• <br />Sate Zip Coda <br />Title <br />Time In <br />I 1 Q AM -. <br />I ' <br />� O I ®PM <br />Time Out <br />Q AM <br />0/. <br />O 3 O; ® PM <br />� � �e � (ANS - <br />-- - O(AFT <br />--- <br />--'- L __I <br />1 <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 />f <br />® Active <br />0 Closed <br />Passenger <br />0 Altered <br />0 Generator <br />0 Hauler <br />IS Outdoor <br />0 Indoor <br />O <br />GPS Latitude <br />-- . — - <br />-- -.0 <br />0 Inactive <br />0 Truck <br />Longitude - <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair <br />0 Trucking Fleet <br />0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer Q Auto Body <br />0 Car Dealer <br />0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler <br />0 Agriculture <br />0 Shredder 0 Other I <br />I <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />0 <br />0 I <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 -Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n <br />n <br />Other: § , <br />Comments (� 0�1� I n S Olt t r l I n <br />t` 1 � <br />ction Form Included: UJfL­Q <br />Comments Included:0�/ �v� ��� �4 -0-- <br />Business Rep's Signature Phone Number <br />Inspectors nature <br />one Number I <br />0 <br />INSTRUCTIONS ON BACK Correct: Incorrect: <br />- White Copy. CIWMB Yellow Copy. Operator <br />X A A4 P ' L 11 [2 3 <br />Pink Copy LEA <br />62081 <br />® ■ <br />