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;. Waste Tire Survey & Inspection Report.-!- Inspection Report Number <br /> rr, S'a`en181(oroa Survey Form - Page 1 ;Z - 1 0 0 6 71 6 <br /> CIWMB 1e1 tt�M M/04) <br /> Glifornia krteg rated Waala MaNgemenl board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TpID. d+ P Inspection Type (Fill one) <br /> Site Suffix: R 1 ` 4 Routine 0 Re-inspection 0 Referral Q Observation <br /> Local r H Referral,choose referral type(Fill one) <br /> Identifier: S GC' , w t 1} �j W��I�J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> 5t` Inspected By Inspector <br /> � lnpc,��S �.cA,�JnlJ�.,c�,.t�l <br /> Physical AddressUr <br /> l Inspection Date L <br /> Time In _ ` Time Out <br /> Business Rep Title 0AM 0 AM <br /> O Z" ®PM 7— 'D 40 PM <br /> -- - — Operational Status TireType Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ATire Count(Whole/PTE) p <br /> ' r o Active ®Passenger ®Generator ®Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude � 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR j 0 End-Use 0 Container <br /> Business Type (Fill all that apply) I <br /> ®New Tire Dealer ®Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part S-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> r 't1111' <br /> 0 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 /> 101 0 1 Other. § <br /> Comments �S oy <br /> % 5Z-rtt`L--�— i�t,s ► D wail\o. M <br /> I13� <br /> Inspection Form Included:o <br /> Comments Included: �71y//J k�rector's <br /> Number. Signa re Phone Number <br /> INSTRUCTIONS ON BAC A lilt P l X E 1l 2 3 62081 <br /> .■ White Copy.CIWMB Yellow Copy.Operator Pink Copy:LFA ® ■ <br /> 0529204.0800 <br />