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l= , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateof181(New <br /> Survey Form - Page 1 17 - 1 Q 1 0 7 4 7 <br /> C8NM8 181(New 04104) <br /> Cellfomia Integrated Waste Management Board <br /> Part A Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' 0 5 ,7 - O Inspection Type (Fill one) <br /> Site <br /> 51te Suffix: Re-ins ection Referral <br /> ® Routine Q P Q Q Observation <br /> Local �nQ If Referral,choose referral type(Fill one) <br /> Identifier: v\`/^1'/.,t„ V Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By / Inspector <br /> Physical <br /> Physical Address `WUV OGwJI�'V 3 1 - ! 0 <br /> 1550 W� Freenen�' <br /> Std n / 9� R3 Inspection Date 0 / <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> G 1^I G Aar <br /> ar — 0 PM 0 PM <br /> si <br /> PrOtlkd'iU'h ,� <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 /> f Q Active 0 Passenger o Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler f)Indoor <br /> O ®Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 PhvoJ b �Q�d <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 OthjU.fC�l.'E_ <br /> e�r:: § <br /> Commentsr\U �� ml fvwS C.6 e, lCLir-� IMUS �Ct� <br /> to s f ve1�r,�es �'erNicL a loca.QyerndorS. T es_ on F'i 114,S <br /> Gt[� k-eplf At- spare '7ivzS fir vekcles. __est fo 1hachyatc The's.wus <br /> No Wo 144073E - <br /> Inspection Form Included:Q y fu �// <br /> Comments Included:Q /Ul <br /> Business Rep's Slgnat Phone Number jtl,�n.ure Phone Number <br /> INSTRUCTIONS ON BACK jEjXjAjMjP1J,1E1 111213 62081 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> 0719304.0046 <br />