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Ire Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CRNM 181 Calif(Now <br /> Survey Form - Page 1 1 6 1 01 3 1 4 6 <br /> CIWMB 181 stew nage <br /> California Integrated Waste Management Board <br /> PartA-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection/ / - Inspection Type (Fill one) <br /> site Suffix: J f 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalS'4s%-- t If Referral,choose referral type(Fill one) <br /> Identifier: aa�.4.�r �;rt� O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> / Inspected By Inspector <br /> Dc' (� <br /> Physical Address 3 7 / c</3 X30 i,vi�'✓.Q <br /> -3 V/o Wer r <br /> Inspection Date L91 <br /> / 0 Q / 0 7 <br /> VC' C�pn C.aT I <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger •Generator 0 Outdoor <br /> O O Closed O Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 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 Q Auto Repair Q Trucking Fleet Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer 0 Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture 0 Shredder Other Aad - r},­ 4e e_ <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility rwm'�RCEllil <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires {�Notice Q1 Vtotaiion 0 Fxtenslorr"; <br /> Y <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Canptiance Deadloie. <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q ; O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 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 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities Q � <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other. § <br /> Comments <br /> —r��s ,ry✓ooC P-0Sw� <br /> Inspection Form Included:Q <br /> Comments Included: t_Pho.�mtumtbefr <br /> slness Rep's Signature Phone Number Inspector's Signature <br /> INSTRUCTIONS ON BACK IEIXIAIMIPI 62081 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0703804.0497 <br />