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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Slallfornla Survey Form - Page 1 1 6 - g 4 8 8 7 <br /> CIWMBWMB1ate of 181(New g4I <br /> California Integrated waste Management Board <br /> Part A-S_urvey BLUE OR BLACK INK PEN <br /> rrBusiness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Z 2 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �,��� ,�� / ��r4`_ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name " J <br /> Inspected By Inspector <br /> �1 AddV15 -o iress <br /> Physical Address � � e� <br /> Inspection Date � 2, I -2� 3 l Q C^' <br /> Time In Time Out .7 <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE} (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> } 0 S Active ® Passenger ®Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> D Q Inactive II*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 Q Trucking Fleet If 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 Q Agriculture Q Shredder Q Other <br /> Part B -inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ] NFtS ' 1AENT:$TATU&- .._ <br /> ---- - <br /> HltdF1Q. 'NFAI> I1VlEN'T: . .,;; . . Q N�atlst 4f vlolatlon Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires - <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. �i4ltfp >lt14 dlins <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements tawta <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CINJMB m m <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days {ff�t�ttlf9tlf0rNQU.OfL�XT} <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q {�fT �+R (l�Pt �nfgGCe)rE�lt <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 /> r..I�S>f�fi�1C�1R <br /> 0 0 Other: §� <br /> Comments / v fah 1'l ✓Ts 7Z �7 a►h� n�x------ �- _ -- — -- <br /> 'f ✓ Ill'er <br /> 15 <br /> 03 5-1+ <br /> 1/ I `��,WS V{1„�CrX •'�Y7�r-- C`�—f't,-e*^ i;�,���YA--S Sf��-Sa. <br /> �f �T' pnq✓.r"ttP�S <br /> Inspection Form Included: O <br /> Comments Included: Q - � - -��13 -- <br /> Rusin ss Rep's Ign re Phone Number I ori t e Phone Number <br /> INSTRUCTIONS ON BA K p � j 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />