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u;r <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> state of call— <br /> c.. '87(New 04104( Survey Form- Page 1 I - 10 0 6 6 1 0 <br /> calffornla Integrated Waste Menagerr-nt Boats <br /> Part_A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Lt ^of g _ Inspection Type(Fill one) <br /> She Suffix: .Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ow-v � -/ C Q CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name UVJ Inspected By . Inspector <br /> m ��► p m a4-,+T <br /> Physical Address <br /> Tao► -� l�'�K��,�� ,,, <br /> Inspection Date O � / b � / D <br /> Time In Time Out <br /> Business Rep Title � ^ O 0 O AM � � � Q AM <br /> Dalt,44t, L(°t,t Yo 1 -t O PM - 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 /> t f �'' ®Active O Passenger ®Generator ®Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude Q Hauler •Indoor <br /> 0 O Inactive ®Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type,(FIN all that apply) — — --- - <br /> Q,New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator;Hauler and End-Use Facility <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of-Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q PRC§42956-RegistratioNDecal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> A <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> � d <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators y �i <br /> av* <br /> 010 1Other. § <br /> Comments -Ws 46m a4d '+,AO W j vicue. <br /> r <br /> �feav�Q n�-�ruls� <br /> Irp -to Y r itA TPy6ices. Vie - <br /> JAM +t I _ ib o ✓i c1c�f ions <br /> Inspection Form Included: <br /> Comments Included:0 <br /> Busi gna urY a Phone Number Ins actors I naturo. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON K g E X A P I L I E 112131 <br /> ■. White Copy.CIWMB Yellow Copy:Operator P' �,... - ® ■ <br /> �'� � UVI 0 <br /> 0529204.1314 <br />