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4925�45QQ53- <br /> Waste Tire Survey:-& Inspection Report Inspection Report Number. <br /> CWte B81California I 1 - 114124 7 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 13 OL�F K [Ell ® Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. Ci l ( _ O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Physical Address 21Ncv Lol L -� <br /> Street <br /> Inspection Date ] / ,P� I <br /> 6 lJ <br /> citl State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM EE : <br /> OPMIII " zl : d PM <br /> LGA►-iA aeZ i I Ma��YIuV►�C_1'�bJ <br /> Operational Status Tire Type Business Role- Storage Type: . <br /> (Fill one only) (Fill all that apply) (Fill all that apply). (Fill all that apply) <br /> Tire Count(Whole/PTE):r ' <br /> .Active O Passenger •Generator *.Outdoor - <br /> - �_ I _ —�--�D O Closed �Altered <br /> GPS Latitude I !,�•I�� O Hauler. O Indoor <br /> o Q Inactive Truck <br /> Longitude - i I ( Q Planned ' O OTR O End-Use *-Container <br /> Business Type- (Fill all that apply) <br /> O New Tire Dealer 0 Auto Repair Q Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel i <br /> O Used Tire Dealer O Auto Body O Car Dealer 0 Collection O,Crumb Rubber 1„. �� <br /> O Service Station Q Hauler O Agriculture O Shredder a Other Z�Jerr"p--"� <br /> Part B-Inspection of Waste Tire Dealer, Generator,Hauler and End-Use Facility ENF,ORCEMENTt$TATUS31 <br /> i <br /> V A ,a„r FILINGyANDMANIF,ES�TRE,tiUIREAAEN�S't -. <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Mlotice idlatic <br /> enslon <br /> O O PRC•§42953-Contracts With Registered Waste Tire Haulers. Ceniplianae Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date; �/•' <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB '' <br /> R tr6edfNOY ' <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days' � � for <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q ReferitA J CIWMB nforeemertt <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compiian`ce No Yiolattons- <br /> O 10 1Other: - <br /> Comments <br /> { <br /> Inspection FormIncluded: O <br /> Comments Included:O <br /> Business Rep's n u Phone Number I is i ature Phone Number <br /> $. o 62081- <br /> INSTRUCTIONS ON BACK Co eco{ Incorrect: 111273 <br /> ��X 1 <br /> White Coptr <br /> Yellow Copy Operator Pink Copy LEA ® ■ <br />