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Waste Tire Surve & Inspection Report inspection Report Number <br /> P P � . <br /> State of California <br /> ) Survey Form - Page 1._ :� 3 - 10 t� 6 6 18 <br /> CIWMB 181 New n.g. <br /> California Integrated Waste Management Board <br /> Part A-Sur'vev BLUE OR BLACK INK PEN. . <br /> Business Profile Inspection.Detall_s. <br /> • TPID Site Suffbc � 3 5 � 9 8 , � 0 ! Inspection Type (Fill one} <br /> ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �- / If Referral,choose referral type(Fill one) , <br /> Identifier: calm �.1 QR 91�1•cYt ��i,H TU 0 CHP 0 CIWMB O'Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name � <br /> y �-t- InspeGed By Inspector <br /> MGGOf iVr(G rtj1'LP- •SeYViC� l-PCU p <br /> Physical Address 5 1 1 <br /> � Inspection Date <br /> Time In Time Out <br /> Business Rep )) Titl(e� CS ®PM b 3 y 5 ®PM <br /> /V10 K.Akj t0l. Df-i i.0 <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) C (Fill one ohly) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ®Active 0 Passenger : 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude ®Hauler �Indoor <br /> O 0 inactive •Truck <br /> Longitude - 0 Planned 0 OTR ®End-Use ®Container <br /> Business Type (Fill all that apply) <br /> 40 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government .Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> I <br /> p Ie Dealer,Generator, Haler and End-Use Facility <br /> Part B-Ins Inspection of Wasteru <br /> Tire .., _ <br /> vanm <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. ) <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entitles Complying with Manifesting Requirements y 4 s <br /> 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB r' <br /> 0 .0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements-for Registered Waste Tire Haulers <br /> ;r <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0• 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § <br /> z <br /> Comments ROwivle IhSP2.C'*&'t `Irl-S 0..K Itte- il%NoWilk ttJaS l'!OtzdS K9 <br /> t?�1�ead ft+.t7�.tifv I�ses re��ster�.d �t��ti►'� Glau_l�r L.J <br /> �ic l I -trew er morn x ovlce .jaer.m ovl tl,. Trot i lu- i Qn lrre vlt!H t wee q w f vers <br /> Fu U nP vJastt, -fu-ts aAoL `fA.e✓L nrV owoa-oL&0 -fines on ste. 7b be_ <br /> Inspection Form ncluded:0 <br /> Comments Incuded:.0'_. <br /> `1�� 0 I Iy I <br /> Business Rep's Sign ure �S <br /> (.CQ� <br /> •,Phone'Number Inspector's nature Pone Number <br /> INSTRUCTIONS ON BACK V �`'I l r ICK P �, t I I p�I,3,1 62081 <br /> ■ White Copy:CIWMB Ak Yellow Copy:Operator L� Pink Copy:LFA t - �� ■ <br /> 0529204.0838 <br /> J <br /> PFS >, ✓+ 4'i'S � .n, '"'' ,� <br />