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Waste Tire Survey & Inspection Report InspectionReport Number . <br /> State of California <br /> CIWMB181 <br /> astJewgage Survey Form - Page 1 - 1 1 - 102568 1 <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business:Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �" s tQ - O)Routine Q Reinspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Filtons) <br /> Identifier: ,Toa � � y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> v f�— <br /> Inspected By Inspector <br /> u-Nli7 y 7Y"a.�&e >a ks 3 9 - l 1 -�t <br /> Physical Address 0 <br /> /;7(009 `ffar/an f?d - <br /> Inspection Date � <br /> Prmch Camp p C¢ 95 3/ <br /> Time In TiiJm''��e Out (� Q <br /> Business Rep Tide0 AM a � 3 O PM ll � 1 I �PM <br /> OAM <br /> V;c,;tDY TA o�rpe z lswgs S�+' a a t' <br /> —- Operational Status 'Tire Type Business Role Storage Type ' <br /> The Count(Whole/PTE) (Fill one only) (Fill all that,apply) (Fill all that apply) (Fill all that apply) <br /> r ?1�ctive Q Passenger Q Generator Q Outdoor <br /> O0 Closed Q Altered <br /> Gp$ Latitude <br /> Q Hauler Q Indoor <br /> O 0 Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Filt all that apply) <br /> Q 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 ®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 + }E <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. a <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. ? yA <br /> Q Q <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers - <br /> Q 0. 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities apt <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators y. <br /> Q Q Other:.§ <br /> commentsEnfere <br /> R jnS - A1RGC 1 t, <br /> _ho -liines ae'e Serviced of fits F�a�•��• Vew sold fo <br /> �,f,�S-}a n-,ev-s bwi' W�.S�'� 'l'I�S cu^e no-�' �12h2h tzf'e� !-rst• aF �t is <br /> c�sf�. cis c/iolaf'ovt <br /> Inspection Form Included:QOil <br /> 4y4fd$�� � <br /> Comments Included:Q— - <br /> B t o Phone Number s ectot i nature. Phone Number- <br /> 12081 <br /> INSTRUCTIONS ON BA t E ?CAM P I L E 1 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LFA <br /> 0529204.0027 <br />