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�i Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> cramB 181(New tCalifornia Survey Form - Page 1 1 5�- 1 01 3 4 2 6 <br /> CNVMgG04) <br /> Califomla Integrated Waete Management Beard <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: oI ®Routine QRe-inspection QReferral <br /> Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: a�I�MQ L(,�,� yt t(a Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /Vl (r - <br /> Inspected By Inspector <br /> 7R Sia /oi Q5*V� 3 9 _ a / <br /> Physical Addre s ? � jlj L <br /> /6-7-77 stow/and Rd. /� V <br /> -a�GtroP iO4 85330 Inspection Date Q / —7 / a <br /> Time in Time Out <br /> Rep <br /> 0 AM 0 AM <br /> Business <br /> `w* Title ( �O ' . O 0 •PM 1 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t t ®Active Q Passenger •Generator i Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q 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 Q 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 A j� �/(�� <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other 414 r+a1'r' ah r <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <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 Vehicle <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 <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <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 /> 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: § {,y'-n �{ .y/ �] <br /> Comments JJE1Q i,� G/�s� .t YNS t 1 WL fO- I L2 %e+W n01 r -�3Sus <br /> uarot ( P5.1 j / f s`r t u�n- P� eALo 2 e F1 �k&e_ -t vs w- se 6 �a+ <br /> t i1 Lal rww,, l� vt k&..P_ Serviced al y'0AA ?L /re <br /> r . <br /> i►1U0� - Viamd,Tt'ref �m Cu4Pd14� G�.S�i'r .,ra✓`iolct:7 �b <br /> Inspection Forth Included: (2M) �l �L .. l !�+Comments Inclu ' \usiness Rep's 31gn ure Phone Number ffXX <br /> toPhone Number <br /> .rel .I n. ISI I,I nip. 62081 <br /> ■ INSTRUCTIONS ON BACK ' ��/' MI P >r�� 111213 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA ■ <br /> 0615104.0744 <br /> d <br />