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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Statefl:alifornia <br /> CIWM Survey Form - Page 1 1 9 $ $ 9 <br /> CIWB 181(Naw 04104) ■ <br /> California Integrated Waste Management Board <br /> Part A-Sur_vey -_ B_LUE OR BLACK INK PEN <br /> Business Profile I inspection Detail a <br /> I TPID- r O _ a } Inspection Type (Fill one) <br /> Site Suffix: I r If Routine Q Re-inspection Q Referral Q Observation <br /> • Local (� If Referral,choose referral type(Fill one) <br /> Identifier: c�tc A JDOLV Q WCC Q CHP Q CIWM8 Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> i Inspected By Inspector <br /> Physical`IddYess 7 C) - ! V / j eb(,it u(lZ <br /> 3030 Iia-fer <br /> C _, ��� Inspection Date / f 1 *� l ) <br /> l! ci <br /> i <br /> f Time In Time Out <br /> Business Rep Title O AM O AM <br /> Ma���v��►a� ka-s�fod a w,�lc�s, � PM � � PM i <br /> Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) n (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply)' <br /> s oc <br /> ® Active ® Passenger 0 Generator ® Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude I 0 Hauler 0 Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned ® OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> (a New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> i <br /> 0 Service Station 0 Hauler 0 Agriculture Q Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use FacilityT$TATU13 _ <br /> _ p_ ILL[AIQ N� i [FiwB "I1JIM> NT %. t, — <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q: llal on Q E7ttanslQn <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> all no, <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> { <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs Within 90 days d f NOVor.am <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers lfdflttVAR, , <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ' <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators / <br /> O ® § f Cc R� i 3s 3- JeLi�r CIJ,r ro I I'G1 easur�s =%` - <br /> Other: _ — - ----. hr... - - <br /> Comments <br /> upon rnT(c,,- ioy-\ vviow;F-e- f s pltdcd by GeVr tV *r-v s hQ <br /> 3" •)Roti fia� a;s+411 ADAJ-et-. . aX 9Do us�cQ -K►w— s� f-t Q � racy Gv-- <br /> re Pao viast�-fzY�S U�t s"i'�, Some rti/afQt• {aid, 'PI rtsej +iVes, area dF- UyiCer <br /> /y OC k2 t?3534"r-"r- 00itifrof, CarrecW i rviim e(4 aJ-ef t , NDVida-66n-s, <br /> Inspection Form Included: 0 <br /> Comments Included: 0 �� - <br /> Business Rep's Signature Phone Number I ctor's i nature Phone Number <br /> 62481 <br /> INSTRUCTIONS ON BACK C+At��'Il�i# f ;moi' _: P L E 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />