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Waste Tire Survey Inspection& Ins Report Inspection Report Number <br /> p P <br /> r State of California0 <br /> t:IWMB tor,(N—04104) Survey Form - Page 1 - 1 7 - 1 0 1 0 7 0 6 <br /> CalHomla Integrated Waite Management Board <br /> Part A-Survey_ BLUE.-OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 I O l ( ' 0 Routine Q Reinspection Q Referral Q Observation <br /> Localsoj'� <br /> If Referral,choose referral type(Fill one) <br /> Identifier: � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Faclllty Name <br /> j(�Ir�nj J on& Inspected By Inspector <br /> Physical Address of �Wnl 2 R O / � <br /> 105-0 t7i'am onoff. S-, _1 <br /> Inspection Date O s � J Q � O 7 <br /> Time In Time Out <br /> Business Rep Title e� [ I�I Q AM Q AM <br /> J w' le //n�S�s-(� �i�G(.tU' �ar ►V 5 _ 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> o <br /> Tire Count(Whole/PTE) D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V 0 Active Q Passenger Q Generator 0 Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q inactive Q Truck <br /> Longitude — Q Planned Q OTR i 0 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler ®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§18459.3-Retention of Manifest Fortes 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 /> 010 Other: § <br /> Comments -41-I(S WW ir0l[lRthv"a— na`rdo A /i✓e5 <br /> kaUe 6e2y► frosar4or From Wtt,S Scj-e &w,ce 1 t i►is tT>, <br /> t 0 . Jrolai, i on s irW 14CJ1• <br /> Inspection Form Included:Q t <br /> Commanta Included:Q 'k�K <br /> Busine- 'e Signature Phone Number I aor's s gnature Phone Nuu <br /> ■ INSTRUCTIONS ON BACK EWAIMI P L E 1 2 3 62081 <br /> 0716504.0044 White Copy CIWM8 Yellow Copy:Operator Pink Copy:LEA ® ■ <br />