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Waste Tire Survey & Inspection Report Inspection Report Number i <br /> =101 <br /> lCallfornia Survey Form - Page 1 6 - 1 0 2 5 8 8 1 <br /> C{WMB 181(Now 04104) <br /> Callfornla Integrated Waste Management Board <br /> Part A•Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- + Inspection Type (Fill one) <br /> Site Suffix: I f j Ci — ro i Routine Q Re-inspection Q Referral Q Observation <br /> Local Q If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J <br /> Inspected By Inspector <br /> p go s '7 c <br /> PhysicalP�Addres` s -39 t <br /> V qg� tvj,6 f- Laic. <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> n O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r Q (Fill one only) (Fill all that apply) (Fill all that apply) I (Fill all that apply)' <br /> i #Active 0 Passenger 10 Generator 10 Outdoor <br /> O 1 Q Closed Q Altered <br /> GPS Latitude Q Hauler i Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — { Q OTR Q End-Use Q Container <br /> Q Planned <br /> Business Type (Fill all that apply) <br /> 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 Q Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> _KENT STATUS <br /> V A l HAl L]NQ AND MANIF(:$T R QUIR MENT$ Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Ggm..plhtticp:Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements pats <br /> O 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 (R9quksd.forNOV or E)(7) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O " Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q;Rehpred l MMS Enforcement <br /> Q 014 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 /> t1 ` <br /> Q Q Other: § ( 0,10).. rice NO V19140109e <br /> Comments MSf e 1 f/eS ftia(t 1 e e� cypv-o x epi-� Z Int e k-S bt� fey is er�t� %i to �t le✓ <br /> Laky n _ire eCa 1 �5� t ), ��r,a4&a r,, IS Un " -i.te 3 �tct"s . <br /> IVCA <br /> ;Inspection Form Included: p� <br /> Comments Included: Q <br /> B iness p's Sig Phone Number1 spector'> gnature Phone Number <br /> INSTRUCTIONS ON BACK !Ct?aI'ilGC, `�ftflQt�1'IAf, h, LI � IP.!. 1 >-1_I. 2TJ s2os1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />