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Waste Tire Survey & Inspection Report Inspection Report NumberSute of ■ <br /> r� CWMeCagrurnla Survey Form - Page 1 1 1 1 0 1 3 6 9 4 <br /> CIWMB 181(Hew Dolga) <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I 0 n _7 u - O Inspection Type (Fill one) <br /> Site Suffix: ! 0 Routine Q Re-inspection 0 Referral Q Observation <br /> Local <br /> n /t If Referral,choose referral type(Fill one) <br /> Identifier: t6� O CHP O CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> / <br /> Physical Address 3 - [ 0 / <br /> I <br /> _3361 Inspection Date / © <br /> Time In Time Out <br /> Business Rep Title / ®AM 0 AM <br /> i( � O PM 1 f 7 O PM <br /> r ( Operational Status The Type Business Role Storage Type <br /> Tire Count(W hole/PTE) ` Z (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that appy) <br /> Active Passenger •Generator 0 Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive O Truck <br /> Longitude - — 0 planned 0 OTR O End-use Q Container <br /> 1.. <br /> Business Type (Fill all that appy) <br /> New Tire Dealer 0 Auto Repair O Trucking Fleet O Government Q Retreader O Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility 'ENPAI2EEMENTS AT a w <br /> iNG ANC►Mai APT R Elk' *� �I � . Notice Of Vaolatton b Extension <br /> Q O I PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers, Compliance Deal nags <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements fi <br /> O Q i 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB ; <br /> O O 114 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days a <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 /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities r <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators a . <br /> Q Q Other: § , <br /> Comments <br /> �,�e,vll•' �0.1�.2 �����- �� waw ��"� <br /> _ - - - <br /> /L orb la r, %� rcrr'eit f5 4�e !e cy <br /> Inspection Form Included:Q ��� p� ' <br /> Comments Included:Q- —� �f L44(0&- ._ewe- Vd6-0 <br /> _ B.u�ess Rep's Signature Phone Number_ Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK A p L E —111i131 62081 <br /> ® ■White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br /> 0633364.k7a79 <br />