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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> ClWM ofCaliforniaSurvey Form - Page 1 I - 1 0 3 7 0 7 <br /> CIWMB 181 stew nage <br /> 4104) <br /> Cellfomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection.Details <br /> TPID- i D ' - O 1 Inspection Type (Fill one) <br /> Site Suffix: J / ;Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �,. L If Referral,choose referral type(Fill one) <br /> Identifier: &.Y1. �Da�1.�WL �v�" 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Pe;-,W q - 1 o <br /> Physical Address <br /> 3333 Sr tfiw j q9 <br /> ^ , Inspection Date D � / I O / O <br /> l/1'R, 6 <br /> LJ` Time In Time Out <br /> BusinessO Rep Title nA 2 }� Q AM L� Q AM <br /> jf-ssAAS vjw-Hn / `A - PM I s 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 /> 1 V 0 Active 0 Passenger @ Generator @ Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 1 0 Hauler 0 Indoor <br /> O 0 inactive f Truck <br /> Longitude - 0 Planned le OTR 0 End-Use 0 Container <br /> j Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> Q 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 '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: § <br /> Commentsn,r,,J._ _ ,p�n e,-.�, "irLc^) u ;v a haf-e0% lus GCji <br /> is <br /> f2A t1�lwt/�c�tiArv�e. �r� Xlt�{s, J ,. 0✓S1QC. GU�C� hscS StY�ic� Shy <br /> r r WIaJ- _ lir't.S 0.(-2 'W�Ic.QPL On -its -PLLaj'asta 1O-rj <br /> nO 'r2 ✓� t 17(n�05 1/lpU� No VIo�CLIL�nS <br /> Inspection Form Included:0 <br /> Cments Include <br /> omd:0 ---- <br /> o el ass Rep's Signature Phone Number I s dor S nature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPIL 1 :2 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0605204.0507 <br />