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JUL-06-2004 04 : 16 PM MATAGA OF STOCKTON 2109 3206530 P. 02 <br /> i • <br /> wiig Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> Stat.B 81(Nrnis r. <br /> °�wMB,a,ite o age) Survey Form - Page 1 l 1 2 . 1 0 0 8 015 <br /> California integrated"riaate ManagemeM Board <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> !MTPID• Inspection Type (Fill one) <br /> Site Suffix ®Routine O Re-inspection Q Referral 0 Observation <br /> H Referral,choose referral type(FIII one) <br /> Identifier: .Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business er Facility Nafne -- -- -'^ <br /> i / fnspeated By Inspector <br /> I-1 t0fislEil—dau <br /> s.r� <br /> �hLuf i <br /> ,rr'"Y� � , ,��• ��z; Inspection Date <br /> i-'code Time In T_inm Out <br /> i Business Rep .�; Title - — C)AM AM <br /> ]:[ <br /> OPM 0 PM <br /> Operational Status Business Role <br /> (Fill one only) (Fill all that aptly) <br /> C/ Cd O Alive 0 GeneYator <br /> Latitude � ` 1 Q Closed <br /> Ci P$ �_1• 0 Hauler <br /> —_ -- O• i Q inactive <br /> Longitude - <br /> � Q Planned Q Er"" <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body •"Car Dealer Q Collection 0 Crumb Rubber <br /> j 0 Service Station '0 Hauler Q Agriculture Q Shredder. Q Other <br /> .........-..._.._...._.. ..._..__.__ .-. ------- <br /> Part <br /> - ---_Part B-Inspection of Waste Tire Dealer, Generator,Hauler and-End-Use Facility <br /> 4 <br /> Q i o PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 010 I PRC§42953-Contracts with Registered Waste Tire Haulers. gulf <br /> 0 , 0 PRC§42956-Registration/Decal in Vehicle �* rA'^' ' * *t�'• <br /> 010 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements c <br /> 00 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB �� <br /> 0;j 0 14 CCR§18459.2.1-Submittal of Mardfest Forms and Tire Trip Logs within 90 days <br /> 010 14 CCR§18459.3 Retention pf4anrfest Forms and Tire Trip Logs for 3 years <br /> fr' +�, <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 01 Q '1.4 CCR§18461-.Manifest System Requirements for Waste Tire End-Use Facilities <br /> 01 i 1.0ther: <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 0 § - - —. -- — <br /> Comments ( r / n t y ( f <br /> �t'1?•.•. �'!- _-.t,rs�a•�.f��ra..- �6'�•-4�(/`".../j�75J!.fj� �' 1 IM�Hr'1'G�T' ���!"j�G <br /> ._'S:"71"' 4..i, t _ •...,.�r.! A•'7k".'fr +.w R✓-,ll,. rIG`.s�ls. "f i' •�.r, /1 <"_, <br /> / <br /> , �: X 'v•v::n:- a. 's �- <br /> f, <br /> INSTRUCTIONS ON BACK � { A hA P 11 I 1. 2 g 620,11 <br /> ■ White Copy:CIWM13 Yellow Copy.Operator Pink Copy.LEA ® ■ <br />