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t` Waste Tire Survey & Inspection Report p p <br /> aen9 Inspection Report Number <br /> State of California <br /> ClWMB astrewaage Survey Form - Page 1 1 8 - 1 0 0 8 7 0 5 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business ProfFle _ _ Inspection Details <br /> TPID- - ' Inspection Type (Fill one) <br /> Site Suffix: l 1— V O ` ®.Routine Q Re-inspection Q Referral Q Observation <br /> Local - ^ If Referral,choose referral type(Fill one) <br /> Identifier: S LC-o, a0. "t� (,www Q CHP Q CIWMB Q Complaint Q Educational Visit. Q Other' <br /> Business or Facility Name <br /> ` _\ Inspected By Inspector <br /> lIk,5 o�j��\ SQ,� ly(_V lC U VSE \) <br /> Physical11 Address `s 3- % - '1 f7 <br /> Inspection Date iD / !l / L *5- <br /> Time In Time Out <br /> Business Rep Title 4 0 AM 0 AM <br /> ( t ®PM 0 ' L QPM <br /> {j Operational Status Tire Type Business Role Storage Type: <br /> Tire Count(Whole/PTE) 1 p (Fill one only) (Fill all that apply). (Fill all that apply) .(Fill all that apply) <br /> r ° ` L ®Active if Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ®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 Q Agriculture Q Shredder e 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-RegistrationlDecal in VehicleP' Q <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> g. 4; <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CfWMB ? <br /> h,d R <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 dayss� <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years a, <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 F: <br /> Q 1 Q 1 Other: § <br /> Comments (inti 5 stn`�d.f►�,(i� .[ rti.r 5 O Y ovs o 5` <br /> lJ'i- L Ge- <br /> V <br /> iti <br /> l er'!YS co\ USC ot', s.".., <br /> Inspection FormIncluded:Q // p <br /> Comments Included:Q <br /> Bus! Signature Phone Number Insp ctor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK dx X i� P L �i� 3 <br /> White Copy <br /> ..y:C tYN_'/sYY <br /> ■ - CIWMB Y—Yellow Copy:Operator Pink Copy:LEA ■ <br /> 0529204. 1082 <br />