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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> crwMl' (No. survey Form - Page 1 1 9 - 1 010633 <br /> C6.t.18t(Naw-ge <br /> CalNomla Ntegratad Waste MarapemaM Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I 0 ' Inspection Type (Fill one) <br /> Site Suffix: 3 L1 (a Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> ,A <br /> Identifier: l S�t�. \1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By ) Inspector <br /> Physical Address 3 q — ' O I J,MA, _ � <br /> I Sof D a AV-e, - <br /> Inspection Date D � <br /> fKaR t� 1 C,+ q 5733 <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> O PM Q PM <br /> 1 Operational Status Tire Type Business Role Storage Type 1 <br /> Tire Count(Whole/PTE) ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ®Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Aftered A <br /> GPS Latitude 0 Hauler Q Indoor <br /> WA <br /> 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 nQ J �'_I_ <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® & <br /> Other (1 I��u CLt *111 G S <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Fortes 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 /> 00 1 Other. § <br /> Comments she i" L "" ' tS W/4f~'• lowino was n0hj! <br /> i . I Rot <br /> re s4er h"r, {tr frtier tr '(f L fS <br /> �_i ►1 �No +�rolo ieYLS n otP d-1 fte&f�s of iriS f'CWDt Frohn_PMMO Sit cllild <br /> Inspection Form Included:0 <br /> i Comments Included:0 9-97,,7) <br /> Businfiss Rep's Signature Phone Number In"MP <br /> urd Phone Number <br /> INSTRUCTIONS ON BACK E X 1 Z 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Rnk Copy.LEA ® ■ <br /> 0708104.0062 <br />