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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California(New 181(NSurvey Form - Page 1 1 9 - 10 13 4 7 0 <br /> Stat 04104) <br /> CalNania Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details — <br /> TPID- Inspection Type (Fill one) <br /> Site SuHbt: .3 7 y 3 7 D I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local (� / If Referral,choose referral type(Fill one) <br /> Identifier. .]�L/i_ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — Inspected By Inspector <br /> n <br /> Physical Address 39 f <br /> 3sSYi l f� r L•L. - <br /> Sn Cl/ � /� Inspection Date 7 / O 6' <br /> Time In Time Out <br /> Business Rep Title ,,'/ ) D n 40 AM / 10 AM <br /> C—,W /� //lOGtc _ / a Q PM / I O PM <br /> f� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /, 6 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r 7 *Active Passenger 0 Generator 'Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days ) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § - <br /> Comments / a^4, <br /> P <br /> /L/a�.'y4,.f��i�ya,u1yr'.Q�vcaC �>y /`cam �'�, �f''�ar- 4�6 2�►��'� <br /> Inspection FormIncluded: <br /> Comments Included:Q <br /> Phone Number inspectors Signature <br /> Business Rep's S i 15U Phone Number <br /> INSTRUCTIONS ON BACK 6, IEIXIAIMIPI � 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> ■ <br />