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Waste Tire Survey & Inspection Report Inspection Report Number <br /> im <br /> State of Callfornia <br /> Cgrated Waste <br /> Survey Form - Page 1 4 6 - 1006505 <br /> California Integrated Wasto Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 �' O Routine Q Re-Inspection Q Referral ®Observation I <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMBO Comp hintO.Educational Visit O <br /> Other <br /> Business or Facility Name Inspected By Inspector <br /> �' IIf_I _ �C_kAc.Phcal Adress <br /> b.3(� Pot(,-, 12,0l'.J FG <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whsle/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> 1 f ' Active ® Passenger ® Generator Outdoor <br /> Q Closed O Altered <br /> GPS Latitude � Q Hauler ® Indoor <br /> D 0 Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) i <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O 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 r f:,� 7't,� <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility <br /> _RN FQlRCA_M NT STATUS _._. <br /> uxt¢a df laEatlon Q ExtensionCAUMMONvas T0UIREMENt8 <br /> PRC§42951W �- <br /> O auler <br /> Registration and Transport of Tires <br /> O O ;PRC§42953-Contracts with Registered Waste Tire Haulers. C .RI�I)�11G0 �3dtlthe <br /> O O !PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> $ <br /> m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB 7T_LTJ; <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Regtf9d fgrNOV t)rEXn <br /> O 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O14 CCR§18460.2 Manifest System Requirements for Registered Waste Tire Haulerstrlf9rClNM�It <br /> � <br /> O O 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities , <br /> O O . 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § / � ,% _" ✓ , y - — <br /> Comments �NI�S l�!?'•'y 4- <br /> 4k <br /> - <br /> �'��^--�'� -�"r-vrl(Gs� ! �-t!y'� -I,r"►"mss G�.-G �Jl� �/.-. se>T'r� JG-�'- <br /> -T v Cans . i���. c+ ►Z"a`197tr�� c,•>t$[Ci�f c S ciC 'r'� hp, <br /> W i�tx.. (,,k,�[i^ ! o►— ►.,e,-� u s<<Q��^c'CJ~�s�r� 4f+ve.5 <br /> Inspection Form Incluied: Q <br /> Comments Inclu Jed: Q - � `�-' � 7 0'X,0o - _ _ 7-0 298'G <br /> _ n ss Rep's Signature Phone Number ins or's Signa re Phone Number <br /> INSTRUCTIONS ONMACK � I 62081 <br /> rwlt <br /> Entered White Copy:CIWM6 Yellow Copy:Operator Pink Copy:LEA ■ <br /> KB <br />