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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stets olCalllorn4 Survey Form - Page 1 1 2 1 01 3 5 8 8 <br /> CIWMB i81(New 0404) <br /> califs mla Intynted W.V.Monaeamenl Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profill Inspection DNdls <br /> TPID- 3 17 - O f Inspection Type (Fill one) <br /> Sks Sufiba (� �( Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(t,Vl- <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> S dress �ineoln �YIe�-c�� <br /> Physical Address J s <br /> 'As �.ev- C _ - - z_ <br /> �J Inspection Date © / <br /> k�� �n `�/ i Time In Time Out lJ <br /> Business Rep Title Q AM O AM <br /> �t^tiV�o� GirU016- Qa��S O PM O PM <br /> - Operational Status AuTlype Business Role Storage Type <br /> � � <br /> (Fill one only) (FBelthat apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> 0 Active 0 Passenger #Generator Q Outdoor <br /> Latitude O Q Closed Q Altered <br /> C7P.S Q Hauler Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 Container <br /> Buetnal Type (FB all that apply) - - - <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 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 /> M <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements z; <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from C I W M B `r <br /> Q 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments dc r � ''s �w lbkowz�la 14Z . ti' <br /> IF <br /> T '/6& d�Ca14* - $90 y Ci ' <br /> kM 10,M CJc-cdAve- pb:�t On%is r �►��cf JloIct <br /> inspection Form Included: <br /> Comments Included:QB-u�F�p�Sl Inape s*SIgnt hone Num_ber <br /> ■ INSTRUCTIONS ON BACK F X A M P IL I El 111-233 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br /> 0626304.0291 <br />