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u@; Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stateof181(NrnW Survey Form Page 1 i 4 - 1006619 <br /> 4 CIWMB 181 Waste <br /> er mage <br /> California Integrated Waete Nanagernent Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q ( Inspection Type (Fill one) <br /> Site Suffix: 1 O 3 8 5 0 I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. & r,,/fl 1 '91 fjt�(d Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V`r� LyJk _ Inspected By Inspector <br /> Pim"` n Pwil 3 R - 1 b I �iw -gill, <br /> Physical Address <br /> 3aa7 Clerk- .Dt-. i <br /> Inspection Date O n / � � � D <br /> S-bt�to n CA- RS I S `� <br /> Time In Time Out <br /> Business Rep Title D '0*AM. AM <br /> V � O OPM / � � O 409PM <br /> - Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ! 5 O O (Fill.one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> IS Active •Passenger 0 Generator is Outdoor <br /> O Q Closed Q Altered <br /> GPS LatitudeQ Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 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 <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 ` b ' b os <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB 7 <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 Fortes 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 /> 10 Q Other. § .aD tlfll� •h Or Tire G & <br /> Comments <br /> QbKb4 ln6pe f m_ IS CLQ� QM 'Ke IiIIIOMrla via-& noW <br /> etfi s 0_WAn Ti✓'r_b amore Waste gVfS and Sells usable lircs_fo <br /> del ti rts-Lufh am r '.sf&td hawerS aKCt idly Al FeSfS W G'e ft Jidet!. <br /> is_adtl disiom I,er and storts more I 'r . least <br /> Inspection Form Included: — h Q <br /> Comments Included: -- (*—7 <br /> •;Busin Rep's Signature Phone Number In s$ignatur ,,, Phone Number <br /> INSTRUCTIONS ON BACK I E 111213 62081 <br /> . White Copy.CIWMB - Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0529204.0341 <br />