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�l Waste Tire Survey & Inspection Report Inspection Report Numberstate ■ <br /> c1WM 181pCalftmla Survey Form - Page 1 I �j.- 01 3 9 a <br /> CIWMB 18,(Mew y <br /> CaIMorNa Inlagnled Wasla Management Board <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O O n - O Inspection Type (Fill one) <br /> Site e Suffix: I `� 4@ Routine Q Re-Inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> IdentMer: joau w. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Triacm Mks waj 6 n 39 - l b Jew <br /> Physical Address <br /> Dcocs Aub <br /> Tr-a cj 1 q5-30q inspection Date 7 O <br /> Time In Time Out � <br /> i Business Rep !le/PTE) <br /> Title 0 PM 0 PM <br /> O AM O AM <br /> IU <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> ®Active ®Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q 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 ®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 /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers- <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other. § <br /> Comments (. al:e r74 I10R JA)0_S ho r'_OLX Brg br <br /> ►'lam5 G� UI�ASf awe/ wt� ✓�m0/es 7Ltres' <br /> EF ), . Al ed aTAres s ,red /n nowm cLY--LVE CO(rn¢v- <br /> oP wy'i r 3 ,ears Dvn �a Jia r�.{ZJh <br /> Inspection Form Included:6 4 �w <br /> I <br /> I Comments Included:Ql —��� <br /> Busi ass Rap's Signature Phone Number Inspfcjoes SI tura _ Phone Number <br /> INSTRUCTIONS ON BACK E X14 M P L 1 E 1 1112 13 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LFA ® ■ <br /> 0622804.0435 <br />