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i , Waste Tire Survey & Inspection Report Inspection Report Number <br /> Statef torDla <br /> CIWMB <br /> Survey Form - Page 1 f 4 - 102 5 8 9 0 <br /> CIWMB 18181(New 114104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspectlon Details <br /> iTPID_ O r ( r Inspection Type (Fill one) <br /> Site Suffix: 7 Is Routine Q Re-inspection Q Referral Q Observation <br /> Local �j If Referral,choose referral type(Fill one) <br /> Identifier: 15C,L0 TO Q J� 01.r.l.1'�- l 41-+y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> CSP -T- <br /> Physical Address 3 O t,! P4i.ltt �Ct� <br /> 33 30 A,-� 7d f <br /> Inspection Date U 3 3 .S <br /> 5 c tD n 9, .;4_ '$ <br /> Time In Time Out <br /> Business Rep Title <br /> e <br /> i O AM I IO APM <br /> MI O PM O <br /> 1vel-f1/1 WOO�r-1� A4v—tPC 6'Le(CdC6Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i � � b <br /> ®Active + 0 Passenger ®Generator I ® Outdoor <br /> O O Closed I Q Altered j <br /> GPS Latitude Q Hauler O Indoor <br /> O 0 inactive I 0 Truck <br /> Longitude — Q Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer 0 Auto Repair O Trucking Fleet ! Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture O Shredder Q Other <br /> I <br /> Part H-Inspection of Waste Tire Dealer,Generator, Hauler and End Use Facility ENPQRCRJHENT STATUS - <br /> A HAWNOANQ 0�A�+!!ff~$T:REQ1JiR Mgl`#8 �Q I O <br /> Not �ice Vip alt(on Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires f <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. I Complli nco pesdtlne <br /> i <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q j 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Dixie M <br /> C) 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB � m <br /> 0 Q 114 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requod for NOV or DC7) <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> I i <br /> Q + Q 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers i Q I:nfamemw. <br /> Q I 0114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q i 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ((( • `g -1 <br /> *1t10 VtQlan4 i <br /> (Other. § <br /> Comments I <br /> �/i �tr� Ma►Lc�2s�s 0� 5c f�.� was��. �ir�-s �1ak�ef �hc� Qut� 2.3 <br /> (�tUr ,i s re Sfi`t�"eC� 1ta�t herr <br /> 6O1deh _ P.-b jkCfS. sib ,,,� <br /> {doorki ' -fib dtict �o avoid ed-fi, l+/as�� firs ilof .� ke S vrecQ <br /> C <br /> oP fropv4y foe , (CCR;T-rtte1gj ,Sec 035q) — — <br /> Inspection Form Included: Q <br /> Comments Included: 6 C s <br /> siness Reps Signature Phone Number In actor's nature Phone Number <br /> INSTRUCTIONS ON BACK CalfCt' :d1 ^ P �L�-1 1 •I 2131 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />