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Waste Tire Survey & Inspection Report Inspection Report NumberState of Cal <br /> ■ <br /> cWMAB181"°ml° Survey Form - Page 1 1 5 - 1 01 x 753 <br /> CIWMB (New 04104) <br /> Ccall"".Integntad Waate Management Board <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / //�� o _ Inspection Type (Fill one) <br /> Site Suffix: ( 3 $ l(/ Q 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: � O Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected BY Inspector <br /> UUd u cu 3 9 - <br /> Physical Address � <br /> -77 �S, Locas+ Alf . <br /> I I�QVh / /' , q5_3&& Inspection Date / &' Q <br /> I l�/"�I} Time In Time Out <br /> Business Rep n Title e' 0 AM Q AM <br /> '�,vAnn1// <br /> J'I( ' •tve' A"Ie- 0 P QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ' /f"J"S 6�.Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler la Indoor <br /> p Q Inactive ®,Truck <br /> Longitude - Q Planned Q OTR o End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility 1 I' <br /> 0 o PRC§42951 Waste TireHaulerRegistration and Transport of Tires = <br /> 0 o PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 o PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> o Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <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 /> o o 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 oOther: § ,,��," .y� I / <br /> Comments IY15 L:f!!J/t � �• I�Qi I/17VV1 Wa5 �!�fa !�k'S vL+L <br /> �15es PSG 1f f iv 2 vice c� Asa. , NAKC(14tS_ks v i egled�,ftft <br /> iAw Zaj -QV_a Cod f � "tPtD ��P�cc&e p lVo V it)la,-fi ons K6t-ed <br /> Inspection Form Included:of J6 <br /> 8 <br /> �{10 -99(� <br /> Comments Included: .C,[/�� - - --- - <br /> �� <br /> Business Phone-Number_ ___ Ins a is Si ture Phone Number <br /> -� <br /> INSTRUCTIONS ON BACK �� � iVJi��� �' � �� V 1 L-'V IMI P I L I E 1 111213 62081 <br /> ■ 0716504.0119 White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> u <br />