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Waste Tire Sui y & Inspection Report nspection Report Number <br /> N& <br /> State B California 11 w 04104) - 1141319 <br /> California Integrated tWaste eManagement Board Survey Form - Page 1 <br /> Part A- SurveyBLUE OR BLACK-INK PEN <br /> Business <br /> Inspection Details <br /> ess Profile - - - - - Inspection Till one) <br /> 1 - - - - - -J <br /> Site Suffix: I 3 -7 3 6 44 6 V l 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local /� ,- If Referral,choose referral type(Fill one) <br /> Identifier: <br /> es or Facility <br /> L -- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Ident <br /> Inspected By Inspector <br /> yf�1\A <br /> P dr ss <br /> CCl Inspection Date b <br /> v � g5R1a- Time In Time Out <br /> Business Rep Title c� S O AM c 5 0 AM <br /> f,�l�4,-( Mc6" � ®PM ®PM <br /> - - - - - -- --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Otherot�2>i &pot: <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> NOW <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 Vehicles <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements f; <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> F <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments - ��i\l�low _�S�'�J:�l�«\ ��_f ,P� ! �� _�l ►��� LS,� <br /> Inspection Form Included: Q �j z17(, <br /> Comments Include --, ----- - --- -- -------------- ` <br /> e p's Signature Phone Number I ct Signature Phone Number <br /> --INSTRUCTIONS BA � �.$ �.< XAi'MIPILIE1 1112131 62081 <br /> White Cop CIW Yellow Copy:Operator Pink Copy:LEA <br />