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Waste Tire Survey & Inspection Report Inspection Report Number <br />State CrWNlB81(NwSurvey Form - Page 1 1 3- 1 01 0 7 0 2 <br />CIWMB California1a1 (New eMW) <br />California Integrated Waste Management Board <br />Sart A - Survey _ _ BLUE OR BLACK INK PEN <br />Business Profile inspection Details <br />TPID -/ !1 - 0 Inspection Type (Fill one) <br />3 9 <br />Site Suffix: ( • Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: -- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Faci I Name U <br />A �� � i Inspected By Inspector <br />Physical Address t/ -1 - ! O <br />sr�o <br />S. 99 <br />Business Rep Title <br />1 310 <br />Tire Count (Whole/PTE) <br />s s <br />GPS Latitude <br />Longitude - <br />Inspection Date V / / z../ / :% 7 <br />Time In Time Out <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0" Repair • Trucking Fleet 0 Government 0 Retreader <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />0 <br />0 AM <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 AM <br />0 <br />0 P <br />0 <br />0 P <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />Q Active <br />(Fill all that apply) <br />0 Passenger <br />(Fill all that apply) <br />0Generator <br />(Fill all that apply) <br />0 Outdoor <br />O <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />0 <br />0 Closed <br />0 Altered <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />0 Hauler <br />0 Indoor <br />O 0 Inactive <br />0 Truck <br />0 <br />0 <br />0 Planned <br />0 OTR <br />0 End -Use <br />10 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0" Repair • Trucking Fleet 0 Government 0 Retreader <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />Comments � ����2�•-�,ti_ �S I _1� �r �r� ,�(_ <br />GLV <br />�y tCAqd <br />-_ <br />6tdu <br />g- , 9 orWsggd- Ares * Cx <br />cd <br />br',Je sf SaC_/g6b9). +-hat Sc .Bol <br />4*0 :taut. ! eChewbr 4&Vj'[15 rl-f re a!,< .Jlle 4PMOAd S e <br />Dismantler 0 Tire Derived Fuel <br />9 <br />Wits no fed : %t+ -S <br />. <br />nspection Form Included: a AL&�_( 110 III <br />`- <br />Comments Included: Q <br />Business R s gnature Phone Number I ctor's g ature Phone Number <br />INSTRUCTIONS ON BACK tM X A P i E 1 3 62081 <br />. 6716504. 0019 White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ® . <br />