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Waste Tire irvey & Inspection Rept Inspection Report Number <br /> State California Survey Form Page 1 1 7 - 1 01 4 7 0 7 <br /> CCOMBB 181{New 04104) � <br /> California Integrated Waste Management Board <br /> Part A- Survgy _ BLUE OR BLACK INK PEN <br /> � <br /> Bualness Profile Inspection Details _ <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: f.� �} G <br /> ` { � J � 6 '# Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: I) CHP Q CIWMB Q Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address � � � ` O <br /> t,;33 ua�� lto ftc of -- -- -- - - <br /> 5�0���� Inspection Date \ p <br /> L Time In Time Out <br /> Business Rep Tit e O AM O AM <br /> Business <br /> ,fvsJi w QPM O PM <br /> Wtll [ 5 - - -- - <br /> - - - - -- - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) ; (Fill all that apply) <br /> f ' 17 0 Active 0 Passenger 0 Generator Outdoor <br /> 0 0 Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive ®Truck <br /> Longitude - 0 Planned Q OTR Q End-Use 0 Container <br /> Business Type (Fill all that apply)---- <br /> 0 <br /> pply) __Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection 0 Crumb Rubber <br /> 0 Service Station Q Hauler Q Agriculture Q Shredder ® Other (?��.,v� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> /� Tip''.✓/� <br /> O 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> / <br /> Q I® PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q O PRC§42956-Registration/Decal in Vehicle / <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from ClWMB <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 <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § <br /> Ccimments <br /> ��- <br /> Inspection Form Included: Q <br /> Comments Inclu : Q - --I �2 6 `-- -- <br /> Bu tress Rep's Signature Phone Number Insp tor's Signature _ Phone Number <br /> INSTRUCTION O ACKjjjfj� <br /> y MAIWIPILIE1 11. 620811 <br /> ile Copy:CIWM Yellow Copy:Operator Pink Copy:LEA <br />