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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CrWM r`'t"°n'� Survey Form - Page 1 1 5 . 1 0 1 3 4 6 7 <br /> CgVMB 191 Waste <br /> M 04!04) <br /> CalNomla Integrated Waata Nanae�em Board <br /> Part A--Surv�_ BLUE OR BLACK INK PEN <br /> !Business Profile inspection Details <br /> TPID- 9 Inspection Type(Fill one) <br /> Site Suffix: Y 3 7 O ' 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> LOL t✓tDQfr.G[,r H 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name QQ <br /> G�ct�c�.s' Inspected By Inspector <br /> Physical Address Gt/3 pis)r/� 09-4 <br /> f2pL � <br /> Y-5-337 Inspection Date C) 0 r <br /> Time In Time Out <br /> Business Rep Title •AM / U e AM <br /> /�,•�((�� �1riClt,s Lc." D O 0 PM / O / / 0 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude0 Hauler 0 Indoor/'/A <br /> O 40 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 Trucking Fleet 0 Government treader 0 Dismantler 0 Tire Derived Fuel <br /> 0 0 Re <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 is Other v <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility 'NFf}tNTA11i5 ". <br /> PRC 42951-Waste Tire Hauler Registration and Tran <br /> 0 0 § eg' sport of Tires Notice Of Violation Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. ,.0 ornpiia acia,Deadline <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 Forms and Tire Trip Logs Within 90 days Y <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: § <br /> Comments AiaeI"TA'_ !L'O� /" dam( O1/ Gl�c�j� �7iGJ �s <br /> Inspection Form Included:0 <br /> Comments Included:0WjFIL <br /> - �Gf a�st>'+'Tt /fig-033B <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK jEjXjAjhkjP1L1E1 1112131 <br /> 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0627704.0064 <br />