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ol�s7a�oa�a <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> � i 4 . 141310.3 <br /> StsU of C-Illomla <br /> • r C"Aii181(N..GV04) Survey Form - age <br /> C.111—is IM.gratad Wash N14-9--M Board BLUE OR BLACK INK PEN <br /> Part A-Surve -- —-- Inspectlon Detaus <br /> Business Profile - �� Fill one <br /> inspection Type ( ) <br /> TPID- R Observation <br /> Site Suffix: 5 7 O ®Routine Q Re-Inspection Q Referral Q <br /> Local H Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility N/a�me `Inspeded By lnspedor ` <br /> pOkS l 0Il1�,on 0� 71-ca-cv 13 - 0 . s& _J <br /> Physical Address <br /> IStmel Inspection Date FR <br /> 1 <br /> 7`ra C 9304 <br /> Time In Time Out <br /> �IY Safe LrP nde —I 0 AM 0 AM <br /> Business Rep Title ,,,,//)) [T]:D <br /> JfPM F-fl• 0 PM <br /> �n Y CQ cr l.o S_ _ _' w!_ge - operational Status Tire Type Business Rola Storage 7Tr <br /> {Fill ane only) (Fill all that eppy) (Fill all that apply) {Fll all thTire Count(WholelPTE) , , ®Active ®Passenger ®Generator ®Outdoo <br /> — — — l -- D o Closed Q atered O Hauler Q Indoor <br /> 1 <br /> GPS Latitude o Inactive Q Truck <br /> -O o Er1d Use Q Container <br /> Longitude Planned Q OTR �_ <br /> Business Type (Fill ail that apply) - Retreader Q Dismantler Q Tire Derived Fuel <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet �Q <br /> Government Q <br /> Q Used Tire Dealer ®Auto Body Q <br /> Car Dealer Q Collection Q Crumb Rubber <br /> Q Other <br /> Service Station Q Hauler Q Agriculture Q Shredder -- <br /> Part B-inspection of Waste Tire Dealer,Generator,Hauler ank� d End-Use Facility E7iaa <br /> TATUS <br /> V q HAULING AND MANIFESTFREIREMENTS 0ion Q Extension <br /> O Q 1 PRC§42951-Waste Tiro Hauistration andTransport of Tires CneQ Q PRC§42953-Contracts with red Waste Tire Haulers. <br /> O o PRC§42956•Registration/Decal in Vehicle mmo O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Da <br /> O O 14 CCR§16459.1(a)(b)(c)-Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§1B459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years i O Referred I CIWMB Enforcement <br /> O o 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O o 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Oin Compliance - No Violations <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> (21-0 Other: § --— — <br /> Comments JJ� <br /> ►►'�.Rj �✓ <br /> lu /�Q�kuo�ne e <br /> ex�r and <br /> f^e <br /> tr <br /> ✓ <br /> V _ ,-- <br /> E.�ction Form Inciuded:`0 G QK 2 0O �`—W <br /> O In clot's St ature Phone_Number <br /> Comments included: Business p's SI a u_ Phone Number 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: (��j EXAMPL 2 3 © ■ <br /> ■ <br /> White Copy CIWMB <br /> Yellow COPY:Operator Pink Copy.LEA <br />