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■ - - -------------------------------- <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> Callfomla Int g tact Waate Ma Millie i8l(New e9�.et Beard Survey Form - Page 1 C 6 - 1 0 0 0 1 <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: © "L -T— }. O , ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local if Referral,choose referral type.(FIII one) <br /> Identifier:. 5 Wh�ow �,��� ce. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit (D Other <br /> Business or Facility Name <br /> J1_ <br /> Inspected By Inspector <br /> *s C)'rw.wh �J wr_ 16<i�tS\N CG11r' <br /> Physical Address <br /> Inspection Date � � � ` 5 � D •S <br /> t� Time In Time Out <br /> Business Rep t- Title {` 4 AM E 0 AM <br /> RUG O Cik ��^�► � \ � O PM , , J ®PM <br /> - - - Operational Status Tire Type Business Role: Storage Type <br /> Tire CountWhole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( ) ' ®Active ®Passenger ®Generator 1f Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> ' �} N001 wl — <br /> a <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. a Irl, <br /> 0 0 PRC§42956-Registration/Decal in Vehicle ,• L � <br /> 0 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements g <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB w .. •� .y <br /> J:- <br /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for-3 years <br /> 0 .0 14 CCR§18460.2-Manifest System Requirements.for Registered Waste Tire Haulers <br /> 0 0. 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § Nry <br /> Comments 1665 M+AL IL L 4 �t,-5 k-S <br /> (S C 4r( L � Lti I wl 9—tV <br /> 0 qkrot1 w 6 V. !(X��p-C. <br /> \_mss Up 6A— �•c.- S o l�_ y it �•M.tJ�t.�, 9�S EZ o qfN- W 4�1� d Qy- CAW <br /> ©�vv-�S�l, W wS�"'L V ►`�' LCM wh �iNv � ec--C..�OS <br /> Inspection Form Included:0 <br /> Comments Included: 7 <br /> siness Rep's Signatu Phone Number Ins ctor's Signatur Phona Number <br /> INSTRUCTIONS ON BACK E X M. P' 62081 . <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> 0529204. 1053 <br /> I <br />