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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> te of calff—ta <br /> spam' 1(New survey Form - Page 1 1 6 01 3 4 7 6 <br /> CMIMB 181(New nag Y g <br /> Callfomla Integrated Waste Management Board `�' <br /> Part A-Survey BLUE OR BLACK I_N_K PEN <br /> Business Profile Inspection Details <br /> TPID <br /> Site Suffix: 3 o / 6- / / 0 - O / Inspection Type (Fill one) <br /> G <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local (^� If Referral,choose referral type(Fill one) <br /> Identifier: JAL . Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V — <br /> Inspected By Inspector <br /> Physical Address 514'aa0T"V'"�'-p yq <br /> Inspection Date (/,� `J Q a t) <br /> Time In Time Out <br /> Business Rep Title (� 0 AM o AM <br /> O `,' /q 0 7 OPM 0 / �/ 0 P <br /> ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> f <br /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> GPS Latitude O Q Closed Q Altered Q Hauler 0 Indoor <br /> 0 Q Inactive 0 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 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel j <br /> Q Used Tire Dealer Q Auto Body Q 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 /> Q 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§16459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§184602-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 <br /> wa1 kvo%� 775 it Y-44 �. rox.. 3S- ud-eoP�c'd <br /> /t+Clu�' t DL( �'ll"G ice. 3 /!/O ✓%D-Pw.►S iCs� , <br /> Inspection Form Included:Q <br /> Comments Included:Q f F-1� �~ <br /> Bus nese Repp Signature Ph ne Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I EIXIAlhkl PIL WE51jR 62081 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy.LFA ® . <br /> 0617904.0414 <br />