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LS4� Waste Tire SurveyP p& Inspection Report Inspection Report Number <br /> State California Survey Form - Page 1 1 9 - 1 0 1 3 0 5 8 <br /> CNYMB 181(Naw 04104) <br /> CaliforniaaliIntegrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details + <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' pC 3 Vf 0 ' <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: J- Joan Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J ^_-, <br /> App �rK(i Inspected By Inspector <br /> Sa•t.�o & b I>ut s�vt Q <br /> Physical A as ( �J 3 "t - 0 1 <br /> � Inspection Date j ' � o3 <br /> ✓I�.rf� ��]tl�1L-� Time In Time Out <br /> Business Rep Title OAM O AM <br /> Pam / I QOh L ©; + (U'A "Wv`' perational 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 0 Active ®Passenger 4P Generator if Outdoor <br /> Q Closed ®Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude - Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet O 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 /> Q Service Station ®Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityHIM <br /> IN <br /> $k <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires , 3 s <br /> Q Q 'PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle s <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB " f. <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> r , <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> L. <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments (�( J2LtIkI 71 t�� 121 Y[ I�1L__ _kl GI ICt Y1 C�Ylf' /DU S Iii C U t/'J - <br /> - ti�'�.S �ut�d ;h .�a l�v�:�+W�.t,_ � sWnvC ►�a-��$�� ✓✓a.rr� <br /> u�c��ckocc�w�ts_ _ �:.fz.�i:es _cam__ CAinlYvt� �o��-cern.,: 1�a�1 /i�t�.il�elzc�r hcc��S <br /> f tr�.s iti LnVrt_LaU Trrt_wC-Gr S_I holi -/01iZ-Sakult 90q'✓I e- ems( - N, _nts ✓���c� i`/t�,.s <br /> Inspection Form Included: ( <br /> Q ` f� \�; <br /> CommeIncluded:Q� �"�"w'-"� x+'98 <br /> Business Rep's Signature Phone Number 41nsor's SI n ture / Phone Number <br /> INSTRUCTIONS ON BACK 1EiXjAjMjP L J1 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0634704.0260 <br />