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Waste Tire Su <br />"r- State of California <br />11ia <br />CIWMB 181. (New 04/04) <br />California Integrated Waste Management Board <br />Part A - Survev <br />09210040244 <br />'y & Inspection. ReporA Inspection Report Number. <br />Survey Form -Page 1 1088063 <br />RI IIF C)R RI erK INK DDu <br />Business Profile <br />Inspection Details <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />TPID - <br />Site Suffix: Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Inspection Type (Fill one) <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 -Tire Program ID Number from CIWMB <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Local. j <br />Identifier: nr t✓1'tT / <br />��/ <br />'T <br />Q CHP Q CIWMB Q Complaint <br />Q Educational Visit Q Other <br />Business or Facility Name <br />Ph cal Add1 ss P�!n C� i <br />L� <br />Inspected By Inspector <br />- <br />3I / lo I r I <br />L,i(-vns_o-rtcm <br />L_a8.0<{ E_ &em_w � <br />Q <br />_ _1 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Street <br />Inspection Date <br />�-CJ <br />10 <br />Time In <br />I -1i AM <br />ali] I <br />Time Out <br />( I Q AM <br />City State ZIP Code <br />Business Rep Title <br />�% <br />I`tl r"� L <br />®PM <br />�zJ LIS19�1, ' 0 PM <br />L' <br />- -- - -- — -- ---- - - —. -- <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type . <br />. _ - <br />Tire Count (Whole/PTE) $. <br />(Fill one only) . <br />(Fill all -that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />f <br />® Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />0 Generator <br />Q Hauler <br />Q Outdoor <br />®Indoor <br />O <br />GPS Latitude <br />O <br />Q Inactive <br />® Truck <br />Longitude - ' <br />g i i � <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q 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 />1 <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 <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 -Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />.0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />10 <br />1 Other: § <br />Comments <br />S <br />Pess <br />Nction Form Included: Q G, �/6 <br />Comments Included: Q (�((Jsiep's Signature Phone <br />INSTRUCTIONS ON BACK C-76) ruff t��. ffiIncorreet� <br />White Cody. CIVj,W Yellow Copy. Operator <br />inspe�ors �lgnazure�Ignature <br />ExaMp l,E' 111173 <br />Pink Copy. LEA <br />Phone Number <br />62081 <br />