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Waste Tire Survey & Inspection Report Inspection Report Number <br /> stateG1WM 181(Now Survey Form - Page 1 ( 7 - 1 0 2 56 38 <br /> G14YM8 187(New 04104) <br /> californla Integrated Waste Management Board <br /> Part A- Survey ._ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i � � `� � � � - � t Inspection Type (Fill one) <br /> Site Suffix: J +r (� Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: ,SeLn 1_10& �� io �°(,{(n`�) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L J Inspected By Inspector <br /> /� I F+Otxt Ch,t►IrtCl <br /> Sail�0�p/ut+1 1 Ok�,�� rW��iG�'�I�rkS lMairvrenef't��' :{ ((�� 11 <br /> Physical Address <br /> +0 yl ^h��� Inspection Date <br /> C <br /> f- t�J Time In Time Out <br /> Business Rep Title (l)AM ® AM <br /> O pf ( PM 0P <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 1 �1 ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 1 Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet ® 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 /> j Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> i <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMEMT>:ST�%Tk '' ti <br /> V,� A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Vltilatloni Q, <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Write° <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. compllanea 0"dllhe ' <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 (R9Cufredtu AlQ1f j �: <br /> to%n yid; <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 <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Ox 7P <br /> 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments P 6wc oy-k-5 Aot,S-e.S ROWL f c-�Wut_d PIG 04 00,-Iro1, <br /> Wasfie direr are- s•turtd in 5efaroJe_ b,_-r iv, yard , WaS.�e 1 zas an-, yxerraf&i <br /> or 3 at a •RMe. n 0JgA1l i1e l ✓va0.i Tuft iC e (OAtpii—Ltp), Was'+:e 4ires sizired <br /> jn e Durvfh p4 c_ &k-s yard, cinch Iia.r,_Il ed by ST Caw4 Road / Zai vi-Lo tice. <br /> Inspection Form Included: Q <br /> Comments Included: - <br /> Business Rip's Signature Phone Number ins ctor's ature Phone Number _ <br /> Correct- <br /> KB <br /> _Incorrect - -:-..... ._JJE xA NIPL <br /> 62081 <br /> (&I-- �/INST tOtlSGN BACK Correct: <br /> KB <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />