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Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />�= Waste Tire Soey & <br />L', <br />Inspection Repor4 Inspection Report Number <br />CIWMB161State of f(New a04104) Survey <br />Board <br />Form -Page 1 <br />16 -10063 1 <br />PRC § 42953 -Contracts with Registered Waste Tire Haulers. <br />California Integrated Waste Management <br />Part A - Survy — <br />BLUE OR BLACK INK PEN_ <br />Business Profile � <br />_Inspection <br />Details <br />Tptp _ r~ f <br />fSite Suffix: 1 3 % I �Q 7 <br />/ Inspection Type (Fill one) <br />y 1 ® Routine O Re -inspection O Referral Q Observation <br />LocalIf <br />Identifier: �(;tGj �tyi C,� <br />/r - <br />Referral, choose referral type (Fill one) <br />O CHP Q CIWMB Q Complaint Q Educational Visit O Other <br />Business or Facility Name <br />M i'(i VOL I e 7-rkS S 11 <br />inspected By Inspector <br />2, <br />Physical Address Yt/ <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />_ <br />v r �e yi yl ! it f 2- <br />S�PC4�_-H t, %1� �� <br />{� <br />Inspection Date 0 r„ I � � � 0 5 <br />V `C�' <br />Time In Time Out <br />Business Rep Title <br />14 CCR 18459.1 a b (c) - Tire Program ID Number from CIWMB <br />Q AM O AM <br />j j <br />�(t be-jcwi �✓OC�I.�Ct (�Y7 q <br />�— <br />_ - OPMOpM <br />Status ( Type Business Role Storage Type <br />- <br />Operational <br />Tire <br />Tire Count (Whole/PTE) <br />14 CCR § 18459,2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />(Fill one only) I (Fill all that apply) <br />I (Fill all that apply) (Fill all that apply) f <br />O <br />it Active 0 Passenger <br />!I & Generator Q Outdoor <br />GPS Latitude <br />O <br />O Closed O Altered <br />O Hauler . indoor <br />O <br />O <br />O inactive <br />Truck <br />, <br />Longitude _ <br />O <br />O Planned <br />® OTR O End -Use O Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer O Auto Repair O Trucking Fleet <br />0 Government O Retreader 0 Dismantler O Tire Derived Fuel <br />O Used Tire Dealer O Auto Body O Car Dealer <br />O Collection O Crumb Rubber <br />O Service Station O Hauler O Agriculture <br />O Shredder ® Other Corson /qkj��O j Y�V7l� <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />PRC § 42951 - Waste Tire Hauter Registration and Transport of Tires <br />O O <br />PRC § 42953 -Contracts with Registered Waste Tire Haulers. <br />�` i��,✓/: <br />PRC § 42956 - Registration/Decal in Vehicle <br />O O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <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 />O <br />O <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />, <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 + 0 <br />( 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />O I O ( Other: § <br />Commentsac� 14.� t,�s Qis dA <br />ayi <br />waste- _ij,�es- rey"VeA-ey k)dsovi so -v Uice., <br />Dne _. <br />� e-bi � �1c�s_f�_ i�✓� 8vr �i� .1/_ie � e ._ ��r_ s o Na ✓i a_.I �7`�� <br />Inspection Form Included: 0 <br />Comments Included: 0 <br />�r^1 �✓='7 ~ � L�j�_ <br />- j� <br />— -- - <br />�.tors S — <br />-- Business Rep's Sign e_ Phone Number I c'ature_ <br />Phone Number <br />- <br />INSTRUCTIONS O BACK EXC %h� AP L E <br />Entered .. ,M:.. _ : <. <br />62081 <br />1104q White Copy: y: ClWMB Yellow Copy: Operator Pink Copy. LEA <br />