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Inspection Report NumberWasteTire Survey & Inspection Report CaliforniaState of <br /> ClWMB 1st(Now Mana a Survey Form - Page 1 1 4�- 1 0 1 3 5 9 8 <br /> Callfomia Integrated Waste Management Board <br /> PartA-.Surve BLUE OR BLACK INK PEN <br /> Business"Profile Inspection Details <br /> TPID- U _ Inspection Type (Fill one) <br /> Site Suffix: (f Q,Routine 4 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J-00� � y� QCHP QCIWMB QComplaint Q Educational Visit <br /> Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Ad ress j <br /> �L ct� o+ Inspection <br /> ^ , Inspection Date a r <br /> Time In Time Out �Y <br /> Business Rep Title O AM O AM <br /> �1 O PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type. <br /> Tire Count(Whole/PTE) C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active ® Passenger ® Generator Q Outdoor, <br /> Q Closed Q Altered smum <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive (&Truck <br /> Longitude - Q Planned Q OTR ®End-Use ®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 ® 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 0. PRC§42956-Registration/Decal in Vehicle ' <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 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 Trip Logs within 90 days ) x <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms 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 /> Q Q Other: § <br /> Comments Re_itlSPCcion `*5 dtaf2 -'rtu TOillow'lm Kks nti zd • &nmoh /r—(eQ-,f )j✓-e <br /> l0 s 7firts Au s ' arck ',One qD V art( b6l waS QIP . <br /> fir o! ecfl� 6P lash- 'liris �e �d �q T✓'► C f: u 6�6. A-I I <br /> �lipla ►S 1 ZVe- ,9f:lrrl C � Trr' -(� ✓J ✓ r� i say <br /> Inspection Form Included: Q f. �,//� <br /> Comments Included: Q - ---�1-(Y I l(�C <br /> _ ess ep's' ure Phone Number s ctor's ig ature Phone Number, <br /> INSTRUCTIONS ON BACK w le A 1k P1,L I Ej 1 62081 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0622804.0430 <br />