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=i Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> et Staten/California Survey Form - Page 1 1 6 . 1 0 1 3 6 8 2 <br /> pWMB 181(New 01104) <br /> coliromla Integrated weste Management Board <br /> Part A-Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Tnspectlon Details <br /> TPID- / 7 - Inspection Type (Fill one) <br /> Site Suffix: 7 1V^ ill IS Routine Q Re-inspection 0 Referral 0 Observation <br /> Local H Referral,choose referral type(Fill one) <br /> Identifier: sa-h <br /> Af Q CHP Q CIWMB Q Complaint, Q Educational Visit Q Other <br /> Business or Facility Name -- - — <br /> Inspected By Inspector <br /> if ¢ <br /> Physical Address 3 - p ( S='6�'o Av,-40 L.--4 4^L.--4 <br /> Inspection Date <br /> Time In V O Time Out C? <br /> Business Rep // Title / ? Q AM O AM <br /> L.>d r17 pP �fL -3J PM 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 /> t Q Active O Passenger Q Generator O Outdoor <br /> O Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Inactive O Truck <br /> Longitude - 0 Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) - <br /> Q New Tire Dealer p Auto Repair Q Trucking Fleet 0—Government p Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder O Other <br /> Part B Inspection of Waste Tire Dealer Generator Hauler and End Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. x a <br /> PRC§42956-R istration/Decal in Vehicles "x <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years a9 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulersil <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 10 1 Q 1 Other: § <br /> Comments Faef e, 3e& oe- J149re ;,ed aK <br /> Atom s/walk r� '-we ,-.e 4-a,w 94�Ae 4;�e 4'e ti <br /> /'c��'-fu <br /> Inspection Form Included:O � � -d� ti +✓e Y��!pS <br /> Comments Included: — rn <br /> Business Rep Signatureto <br /> _ Phone Number Inspecr s Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK E X AIS P L 4 2 3 62081 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 052,---04.0279 <br />