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Inspection Report Number <br />r �«. <br />Waste Tire Spy & Inspection Repor p p <br />1113 State of California � �� 1 <br />ii:.. <br />CIWMB 181 (New 04/04) - Survey Form - Page 1 1 0 1 0 8 9.3 <br />California Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -[J� <br />Inspection Type (Fill one) <br />- <br />Site Suffix: I 8 Z, q Q Routine (D Re -inspection Q Referral Q Observation <br />Local If. Referral, choose referral type (Fill one) <br />Identifier: S.Q n Too,U 1 n C 6c. n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name Inspected By Inspector <br />Physical Address 0 <br />641 E. Charter kkhG4 i --- -- <br />Street <br />Si <br />Business Rep <br />A) P x <br />Inspection Date Z 0 Q 8 <br />C_A g15Z.C)6, <br />State ZIP Code Time In Time Out <br />Title I m' m 0 PM m' m O PM <br />-11k ao ex <br />moOperational Status Tire Type Business Role Storage Type <br />Tire Count (Whole/PTE) ❑ l� EIIA <br />(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that appl <br />f ®Active (Q Passenger Q Generator Q Outdoor <br />0 Q Closed Q Altered <br />GPS Latitude m . Q Hauler QIndoor <br />0 Q Inactive Q Truck <br />Longitude — FT]Q Planned Q OTR Q End -Use Qi Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />0 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 I I <br />1 <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility ENFORCEMENT STATUS <br />V <br />I A i HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires - <br />Q. <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR §18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />1 Q <br />1 Other: § <br />Comments �r <br />qn—pR ! o �' - ► 5 c' c� G - 'C U <br />11<214, <br />o4eA AlL n Ir ey 10 its v 10 � c i -I of s_ a f e Ck c- c u n c.e r n -1� ave <br />Berl C-0C•{e- (?_8 TOCkII+_—a-L(lQyI Cli �rl C j CID � <br />C-) 1 :.A l o r� <br />Inspection Form Included:Q', <br />Comments Included: Q <br />Busiriess Rep's Signature Phone Numbers Ins ctor s Signature Phone Number <br />INSTRUCTIONS ON BACK Correct:0 Incorrect: X} .A���'�l p IL I E I T112 3 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ® ■ <br />