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Gia <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State tCalifornia Survey Form - Page 1 1 4 - 10 3 4 6 6 <br /> CIWMB 181 New 04104) <br /> Califomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- aInspection Type (Fill one) <br /> Site Suffix: J 3 3 g g 9 0 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local � - If Referral,choose referral type(Fill one) <br /> Identifier: �� r}.t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> r Inspected By Inspector <br /> Physical Address O uAB0—,N,AO o-4 <br /> 13 C&-r4 <br /> Inspection Date O /�/ I / C <br /> Time In Time Out <br /> Business Rep Title / / O AM / O AM <br /> �J ( 3 ' -3 6 • PM / y / / PM <br /> OWAAf <br /> -- Operational Status Tire Type Business Role Storage Type <br /> S <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / •Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude <br /> O Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> 0 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 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 Q 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 Q <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements r <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 <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 C <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities t> " a <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *)a <br /> 1010 Other: § <br /> Comments 4al j/Z Jpse yG.'b„ +`I dav 2Gt"e ^0J4" <br /> rax,'�: ✓oa�.`�r� Ji/)G ,�r"d .�e %tee r'lage-rye <br /> y�ry /.3"0 W%,l / d ,�°rte ak -P,pe. N' a" ' s <br /> tll'-ewes 4o4m /refyx <br /> Inspection Form IncQ <br /> luded: /p <br /> Comments Included:Q <br /> s ess Rep' Igna u Phone Number Inspector's Signature _ Phone Number <br /> r 62081 <br /> . INSTRUCTIONS ON BACK �t{ E Jf R M P .i. E <br /> ?01 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 0617904.0235 <br />