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Waste Tire Survey & Inspection Report Inspection Report Number ■. <br /> Stateor 81(New Serve Form Page 1 o i Q 2 6` 3 7 <br /> CIWMe 181(New nage Y ('t <br /> Calltomla Integrated Waste Management Board `� <br /> Part A-sunre _ BLUE OR BLACK INK.PEN. <br /> Business Profile Inspection Details <br /> TPID- 1 '3 5, 1 � � u � O , Inspection Type (Fill one) <br /> Site Suffix: T 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ If Referral,choose referral type(Fill one). <br /> Identifier: �(' (� /f, Co O CHP O CIWMB Q Complaint 'Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address ss-sh <br /> Fde. 3 q - 1 ) Te <br /> V ►1.y�-L R'4-t Z <br /> C�: _�,; Inspection Date �j Cl / / D 5 <br /> tZCtci Com- 1%j�l C <br /> Time In Time Out <br /> Business Rep rTitle / ®AM Q AM <br /> k ac-g��a- �y r� I►rZ.��.5' � f�; .. O PM I � ' � S �PM <br /> Operational Status Tire Type Business Role. Storage Type <br /> Tire Count(Whole/PTE) C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J ®Active ®Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> 0 O Inactive O Trude <br /> Longitude O Planned Q OTR &End-Use Q Container <br /> Business Type (Fill all that apply) . <br /> ®New Tire Dealer O Auto Repair Q Trucking Fleet Q Government O Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture O Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility t <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O ® PRC§42.953-Contracts with Registered Waste Tire Haulers: <br /> O PRC§42956-Registration/Decal in Vehicle <br /> 4 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 14 CCR§18459.1(a)(b)(c)=Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years 4 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers A, <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities »xz 'b' Msw h �ryt, <br /> 0 ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators , <br /> Q 1 Q 1 Other. § w G <br /> Comments ROkt+yte fhs�ec,FzOrl S CSA i4 Gtyl[ `F�t2 T8 ��O IN11 LG I^�GLS Bio f tit <br /> Reqi s+ered IlVix5tt?- -f(ret A aaa,k r Lakin rZw D as Waste ttYt s ,Prows �a' aJifiil <br /> once pw W,w(c . MavuJ4.st in✓6 cesy.ew4-Cil -coon rzsyrl2St. HaIF op fA2 <br /> iVIV0'-C,e_S 010 r1of Glave Corr �f TPtb vious `n s 'o n of <br /> Inspection Form Included:(� %09) - Q <br /> CommentsIncludetl: ^^"" '2 1493 <br /> Business Rep's Signature Phone Number Ins ctoes t nature' Phone Number <br /> INSTRUCTIONS ON BACK , — i14 P (. t 1,Z 3 62081 <br /> ■ f ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br /> 0529204.0836 <br />