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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StWMBate 1 allfornla Survey Form - Page 1 i - 1 O Q 8 0 8 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> ! Site Suffix: <br /> 148 Routine Q Re-inspection Q Referral Q Observation <br /> I <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CNP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical AddressS <br /> 3333 A a4r-> <br /> Inspection Date O / 0 6 / O / <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> G O PM O PM <br /> max= {���117v�.t. �.b�✓;cam <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) q to C Z7L (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> 0 Active • Passenger • Generator Q Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q 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 •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 I ENFORCEMENT: t &V-.x <br /> V s. A HAULING AND MA (FEST REQUIREMENT8 � . <br /> 0 Q0 Nntiai of ylvUllt[# <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> yy i5 <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. CQrttpll#RCYy�I � � Jr <br /> Q Q PRC§42956-Registration/Decal in Vehicle y` <br /> Q i Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements q y' 1 v <br /> 2Y76 <br /> Q 114 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 Tri Logs within 90 days <br /> figts�r �tx � "jA�4 <br /> � § P 9 y <br /> O ! O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Q <br /> 9�stered Waste Tire Haulers > y•.y ,� /� i���,.,i'/rte/i <br /> 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities x , �' <br /> Q , Q 114 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 4 li /i <br /> O Q I Other: § `>, :�fr %��:%: :•/ i` �F,;! <br /> Comments (��q r �� cy- ¢., 4-3, 4 —f p �,,94- 'f•1 k-2-5 q / L ewk_. R 4 / A. !/ 4, w,\54z• 41," <br /> PP t^a`I L-+ r�rl, 4-� /�.��S7� T(►�1 a^2i ►�r- <br /> g�f n `��l pro.--p G i vJl�^'1)(� •e w�Q [ na r� <br /> o'C' �xlY� -f'1.'L:S C�q�> ��—Pa,.•.�� .� �-�, �-�r�,s f�-�/�� ISG sal b•p.Gi IY�"AiCcY t„-..1�G� <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Slgnatur Phone Number tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cts =ln pt ect I E X A:m: P L I <br /> White Co y:C!W M Yellow Copy:Operator Pink Copy:LFA <br />