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== Waste Tire Su :y & Inspection Reportonspection Report Number <br /> ARII State of California <br /> CIWMB 181(New Survey Form - Page 1 I 1 - 1140698 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details 1 <br /> TPID- Inspection_ ` Inspection Type (Fill one) <br /> S o <br /> Site Suffix: I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � ' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 1'011 C-� (A i �),1 r-,c_,A t- cel T-c.►,14- <br /> Physical Address <br /> lcc, X Rd <br /> Inspection Date o 0 1 0 <br /> Sf�e iCtc�n CA ! S <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> Operational Status <br /> Tire <br /> eTBusiness I' Storage <br /> Type <br /> (Fl one only) (Fill apply) (Fill all that apply) (Fill all that apply) <br /> Y)Tire Count (Whole/PTE) 4 3 <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> Latitude0 Hauler 0 indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 End-Use 0 Container <br /> 0 Planned it 0 OTR I <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMT;S <br /> ENTATUS <br /> _. — <br /> G AND aMANIFEST IR REQUIREMENTS <br /> V , A ` HAU�IN <br /> 0 0 PRC§42951 -W Registration and Transport of Tires '01"Notice Violation„ _0 Etehslpn <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. �Gotnplian� t?�ad)ln�,, <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 114 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days 0 fp'f� ?1of <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulersi <br /> 0 0 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 /> 0 0 Other: <br /> Comments <br /> powvll (I-e-- -11 nC f �r <br /> vvc-'If d- . <br /> Inspection Form Included: 01 <br /> p Comments Included: )(- - -- - - 1-�Oy� V�'$ --0623 <br /> -- - ---- <br /> I Business Rep's Signature Phone Number nspector' Signature Phone Number <br /> INSTRUCTIONS ON BACK C.Cvrr t l oa f 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink tf <br />