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rirr Waste Tire Survey & Inspection Report <br />■ n <br />State of Callfomla <br />CIWMB 161(New 06104) Survey Form - Page 1 <br />Callfomia Integrated Waste Management Board <br />'art A - Survey <br />Business Profile Inspection Details <br />Inspection Report Number ■ <br />1 2.1013480 <br />BLUE OR BLACK INK PEN <br />TPID - ^ ' Inspection Type (Fill one) <br />Site Suffix: ( 0 Routine Q Re -inspection Q Referral Q Observation <br />Local <br />Identifier: _)920L- t�02Qt� h <br />Business or Facility Name O <br />L Q•,dw, �rC. <br />Physical Address <br />44IOZ 2P. <br />_5;AVd44z&' <br />Business Rep <br />-! i` &�• 'Itl"x�r - <br />Tire Count (Whole/PTE) f <br />GPS Latitude <br />Longitude — <br />Business Type (Fill all that apply) <br />eooe Qs'z /s' <br />Title <br />r 6 <br />O <br />O <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />3 9 - / � / craQO�•rr,`� �� <br />Inspection Date 0 S / I) Z/ Q 6 <br />Time In <br />Time Out <br />yL� <br />/0 <br />2 <br />/ <br />/ QPM <br />O PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) (Fill all that apply) <br />0 Active <br />• Passenger <br />0 Generator <br />Q Outdoor <br />Q Closed <br />Q Altered <br />Q Hauler <br />0 Indoor <br />Q Inactive <br />0 Truck <br />Q Planned <br />0 OTR <br />Q End -Use <br />Q Container <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 61.0 a..e. _Olf R'94 i_Q <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 § 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 1Other: § 1 //- <br />Comments Q.1,, —,. �h„f�pp1•T7�f L�e�f' z Curw W-0, �j0 Lyad l.� V4e-./ <br />�W �r�^10 /Y30 y 7Y - o f �/r�.� ewe Ka,4✓ LQ�fi ,lr �u �e J. " <br />�i-rrPJ . � � % Iti vDi Gt1 vi �✓r.P eye �, /^< pr�¢�.,+c , �f/py a-��.I� fur <br />nspection Form Included: <br />Comments Included: <br />INSTRUCTIONS ON BACK <br />■ <br />White Copy: CI W MB <br />0617904.0421 <br />1isy— 73x'8 /z.."4 p <br />Phone Number Inspector's Signature Phone Number <br />P L E 1 Z 3 62081 <br />Yellow Copy: Operator Pink Copy: LEA ® ■ <br />