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UH, Waste Tire Sufty & Inspection Report Inspection Report Number <br /> Stat W6CWMBr 81t1fornla(Now 04104) Survey Form - Page 1 14 - 01 4 7 9 <br /> Callfornla Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> �Buolness Profile — Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: 1 3 Z Cj If Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Business Q�� J pti y�{� � CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> ss or Facility Name ������+++ <br /> _ inspected By Inspector <br /> Physics Address f r S <br /> C00 % v f� � 124 <br /> Inspection Date D 72— <br /> b 7 <br /> J__D4� 6 �5z-7�— <br /> 72—Time In Time Out <br /> Business Rep Title O AM O AM <br /> /� L1 O PM O PM <br /> 7 Operational Status Tire Type I Business RoleStorage Type <br /> Tire Count(Whole/PTE) o j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler f9 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - 0 Planned I Q OTR 0 End Use Q Container <br /> I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 o Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use FacilityI�ATUR <br /> �— <br /> �a h <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 o PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 o PRC§42956-Registration/Decal in Vehicle <br /> o 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> ° <br /> 00 - 7 <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days " <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 .14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> _: : <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities r/ _- <br /> o <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ` <br /> 0 0 :Other: § _ <br /> Comments ✓� JJ T d 6c,5 hD11 T kK vc?_ <br /> 11 �Lril r _y 1'��lg !n <br /> �,��'�.- .��',,.� ! c..,,�:�•)-�S-F's �r-�►W,- w4s�'�- --�'i'�n4- Gam/�,i�-s., <br /> Aui►� �� �� 13" -�►'1^e-S �i r-,.- <br /> 3 -7 05 <br /> Inspection Form Included: Q <br /> Comments Included: —� — - - - - - 'U <br /> Buslness Reps SI atur Pho)te Number In 's Signatur Phone Number <br /> d ' 62081 <br /> INSTRUCTIONS ON BACK1 I <br /> rf '.111 <br /> M 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />