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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State er181(N.California <br /> Survey Form - Page 1 12 . 1 0 1 3 0 1 9 <br /> CIWMB 1a1(Naw 04104( <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I ' j( / Inspection Type (Fill one) <br /> Site Suffix: (J I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> T� l s - f � ��I`� r - I Tom, <br /> Physical Address �{1lJl L <br /> 1131 I)K n <br /> Inspection Date 0 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> (/-'�(},/� � � O PM QPM <br /> -- Operatlonal Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (FIN all that apply) <br /> � � <br /> 0 Active IS Passenger ®Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Auto Repair 0 Trucking Fleet 0 Government Q 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 <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. x 5 <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements egg <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB .. <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 . 0 114 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 <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 tI)IOW I s 1 rwS r <br /> _ c <br /> juts rVionA <br /> � _S Aenn In <br /> Inspection FormIncluded:0 <br /> Comments Included:0 <br /> Business R ure Phone Number I sp ctor's SI nature Phone Number <br /> INSTRUCTIONS ON BACK 1EIZAIMIPILIE1 1Z 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0629804.0346 <br />