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Wi Waste Tire SA%ey & Inspection Repoi , Inspection Report Number <br /> Stale (California <br /> CJWM Survey Form Page 1 i 7 Q 2 $ 4 4 <br /> C1WMB 181 New 04104) � r <br /> California Integrated Waste Management Board <br /> Part A• Survey BLUE OR R BLACK INK PEN <br /> Business Profile- _ _ �+Inspection Details <br /> TPID- 1 r 1 �{ Inspection Type (Fill one) <br /> Site Suffix: I C9 `f -1 s r 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 61 To "i-VAL 00t«j. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Phystcall�A dresDs 3 1? f � <br /> Inspection Date <br /> `1 G Time In Time Out J <br /> Business Rep Title 0 AM 0 AM <br /> M 0P QPM <br /> ��11� "�Z A� �� <br /> Operational Status Tire <br /> p � Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f � <br /> ® Active ® Passenger ® Generator Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauer I Q Indoor � <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End Use Q Container <br /> i <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment 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 Q Other <br /> Part B - Inspection ofWasteTire De��all��err,p, Generator, Hauler and End Use Facility <br /> 0� Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires !✓ {Ql#UQ[f' Q polop I <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. 40rtfi#1 - <br /> 0 o PRC§42956-Registration/Decal in Vehicle y. <br /> Q 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements I I <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> ✓t � fOFVQiFCL <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> y s I <br /> Q 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 ;- �s 3 <br /> 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <• c �,.:•,�� �-�`.� � <br /> o '�✓� ¢f s3s' .' � .r <br /> 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ,. <br /> O O <br /> Comments f\4e��sfQrOd Tre. iiktn- IHI N T[RE (oW_od 1 D 5--01.3)0) -riv-e5 rIclite d up <br /> 2�rS/ 5 (7S piW t�) /�'aqw� sus �✓ -f z�1 o rt��ri�l�S V�e lVec�. lel ct i tl`�aj 1j <br /> - uF�sfs o,1 9.` f� <br /> �r v'ee years fir ► <br /> w�c� rtSPe1 bran. <br /> dnspection Form Included: 0 < (J�/,��( gq /,, <br /> Comments Included: Q - - — it <br /> - r 0 — ( �`a <br /> Bus' ss ep's Signature Number I "to Ignature Phone Number <br /> ww.05! <br /> INSTRUCTIONS O ACK u yfpsv �� j 62081 <br /> White Copy.CIWMB Yellow Copy;Operator Pink Copy:LEA <br />