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=_ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StatetCallrornle <br /> CIWMB <br /> Survey Form - Page 1 1 3 - 1 0 Q 6 l 9 9 <br /> CIWMe 191(Na. <br /> California Integrated Waste Management Board <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details . <br /> TPID- Inspection- Inspection Type (Fill one) <br /> Site Suffix: O ®Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: &4't' �Q ckn Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name fk—) �y rte/ <br /> 1.1 wt.t� kl?e R/S /v0d4c1/P1�/ /Mc �✓oc(O Inspected By Inspector <br /> Physical Address 33 r D I J <br /> a�D Cr <br /> C4 95;L tj D Inspection Date <br /> V Time In Time Out <br /> Business <br /> /Rep <br /> ��,I Title / Q AM �f Q AM <br /> 7�i�✓i+'l l�-�Ow.S k{ r s�� � - � �� ®PM -5- O ®PM <br /> Operational Status Tire Type Business Role •Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ®Active (9 Passenger ®Generator O Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer Q Collection Q Crumb Rubber cL <br /> O Service Station Q Hauler O Agriculture Q Shredder ®Other G (40#WA ' 1C211T�-I i Ire l <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> III 1. <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements <br /> O Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O other: § <br /> Comments R 11 VSBPC�ZOn S G>taF► t `rtIP_ 4 t{1owi-W Was ptoTej: `� <br /> �a� �s qn a��,,�,p�,ent �'-e►t�-a.Q J.�legit `-K�a.� �� L¢s Schft�a.6 7'trts {w- <br /> g�(_—hr-� CLKd SPOSah' 2[- 1101 iecs -�i�c�J r /41/ u,5ed *)�s on &�-v <br /> Qre ustd _Ar _c,�are klopas� fte;ej an Sn . Lififa-�/�e i dis-cir.M, <br /> Inspection Form Included:0 �3yc <br /> Comments Included: OD g (� *Spctar's' <br /> �Busing R s SI nature Phone Number i natuFr� Phone Number <br /> INSTRUCTIONS ON BACK "IIID �Ip v 11 Aj*j P 1L 1 EI 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy.LFA ■ <br /> F11-RR404-L1530 <br />