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Waste Tire Su, y & Inspection Report4pnspection Report Number ■ <br /> State of California <br /> CIWMB181(New 04104) Survey Form - Page 1 Il - 1140687 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection I Inspection Type (Fill one) <br /> Site Suffix: b ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> -- ---- -- <br /> Business or Facility Name Inspected By Inspector <br /> I-LA_ fe V CQ,Physical <br /> Physical Address 3 ` o I <br /> r'1Yv1.CtA,'tOl� 1,c�P�}i C:t�. <br /> icnso <br /> r Inspection Date C) ! 1 <br /> Lt/tC,L, CG-vim, 1 CA I s..z 3 ' Time In I Time Out <br /> Business Rep Title O AM _ O AM <br /> C) o2 4 O PM o q ® 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 /> �s S Q Active Q Passenger ® Generator ® Outdoor <br /> 1 <br /> O Q Closed Q Altered <br /> GPS Latitude <br /> Q Hauler Q Indoor <br /> 0 i Q Inactive ® Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> BusinessYP ( ll all thaPP y) <br /> Is Tie DealerQAuto R <br /> e air Q Trucking Fleet QGovernment Q Retreader Q Dismantler Q The Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 4) Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility N I��E)VIENT: TATU;S <br /> i <br /> V A HAULING AND MANIFEST REQUIREMENTS , <br /> < t <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 VehiclebH <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive 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 Other: § <br /> Comments <br /> �au�31/�y _ i✓1S _ '�� o tom-- �1�S�r�.�_ ���e-- ��Lc�„�i✓�� <br /> -- <br /> Inspection Form Included: ® •`/ � � C�,y��Z o��� <br /> !i ll3Y'11 /� ;nspect Comments Included. Business Rep's Signature Phone Number or's Signa ure Phone Number <br /> INSTRUCTIONS ON BACK Coirrect;i fr�tirre # � Ej Aj p I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />