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c]9i'�305n�� <br /> Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> State of 81(Na. <br /> N nla 11 - 1088099 <br /> CIWMB 181(teManag) Survey Form Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> r Business Profile Inspection Details <br /> TPID• rrl, inspection Type (Fill one) <br /> Site Suffix: ( 3 y 3 3 V 3 v�] *Routine Q Re-inspection Q Referral Q Observation <br /> Localo If Referral,choose referral type(Fill one) <br /> Identifier: -, U Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> A acustrK 6YL& 3 q - <br /> Physical Address — I li ! �Q 11{-v- <br /> 6,5- <br /> v-55 yobe4nc fee 16r✓e <br /> 6'��� nom/ CA /�63� Inspection Date D y / g / O Q <br /> ��II L C� Time In Time Out <br /> Business Rep Title / J 0 AM IMAM <br /> V (f 11 f Cr,✓Yi S 0 �N{/�Q i� ( O PM / / O PM <br /> — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �^ T (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r f ) (�' ®Active (r0 Passenger (V Generator ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 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 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder f Other ff6tk1h1 ChJTd 06WV V 511 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> y. ' HAULING AND MANIFEST REQUIREMENT§ : = <br /> O 1 O PRC§42951-Waste Tire Hauler Registration and Transport of Tires O�yottce 1iolatlo Exte o <br /> O O PRC§42953-Contracts With Registered Waste Tire Haulers. Compliance`,Deadline. <br /> O O I PRC§42956-Registration/Decal in Vehicle <br /> O O '14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days 5. (Required r11111 A. <br /> NO ori7CT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years t' <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB ceme t <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 014 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators y' <br /> I (1�In Compliance No.. lolationsn:;: <br /> O O :Other. § <br /> Comm'ents�, de <br /> ✓ b' T w h� Cdr Gt/'1 0 (l Ii.LI '- 7�-kCk <br /> SGS _-�rv% d 0 — Ie. ark. err cC� LJ <br /> r"e n Iraile� <br /> Inspection Form Included:®I ^ <br /> � Comments Included: rA � G� <br /> 1 <br /> B siness Rep's Signature Phone Number Ins a o—es Signature _ Phone Number <br /> . ( <br /> INSTRUCTIONS ON BACK Co ect: Incorrect: of E X M P L E 12 3 62081 <br /> 17 White Copy. IWMB Yellow Copy Operator Pink Copy:LEA ® 0 <br />