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r=== Waste Tire Survey & Inspection Report Inspection Report Number <br /> P P M <br /> Btatoof SC1(Noa Survey Form - Page 1 1 4 - 1 0 1 0 6 0 4 <br /> CMIMB 187(Naw nage <br /> Caleomia Intagrabd Wsets Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- / 3 / O O / Inspection Type (Fill one) <br /> Site Suffix: t,Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name)l/ <br /> IV U Inspected By In <br /> TI-410 Al�CIA, <br /> Physical Addres .__,,��, 3 9 O ��((,/t�_' I Q _ <br /> '2.(e8a .r'//��L,.t Qla.3o' ..p • <br /> -1 cC C-+ !�/1^-r.30V Inspection Date 02 / 2 Z / 0 <br /> Time In Time Out <br /> Business Rep n Tittle Z h J� O AM 0 AM <br /> Ro btAt sins ofew rI v��J'L r O PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f �J ®Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 11111 Indoor <br /> O 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 ®Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 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 Forms 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 /> 0 0 Other: § ,�,0. �/ /� ,, c/( <br /> Comments psn,¢fb4 W fD`` <br /> a"roy-twupeQ_, t v►�.�lti- ( `i- r�,i i euseol Na <br /> �oa2tions ~t�d - - - - <br /> Ilnspedlon Form Included:0 <br /> Comments Included:0- <br /> Buslnes gnature Phone Number [ ors SI ature Phone Number <br /> INSTRUCTIONS ON BACK P E X �0.IMIPILIEI 111213162081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0708104.0091 <br />