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F11. <br /> Waste Tire SL ey & Inspection Repor. Inspection Report Number <br /> > <br /> Stateof11all(ornla Survey Form - Page 1 I - p 0 3 0 6 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste 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: Q Routine O Re-inspection Q Referral Observation <br /> Local IJP^'•" If Referral,choose referral type(Fill one) <br /> Identifier: � (� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> S h n D�&e., Pau-4 S be-Pa+ - j az- <br /> Physical Address <br /> 4 f 01 Si A r. w-+ VVA-y <br /> Inspection Date 060 / © `? <br /> Time In �[/ Time Out <br /> Business <br /> Rep�C (� Tittlle4t O AM O AM b6f+- f'�L(�yl� QPM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Who�e1PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> b Q Closed Q Altered ' <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 ® Inactive Q Truck <br /> Longitude - Q Planned Q OTR O 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 --f raC-Dr <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other pa,- -s vjo_►r47oLtS e-- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility [ENFORCISM NT STATUS <br /> p HAVMA M,G MA I{E fi F �1Wa11MeNTT <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of IOlattOn Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. CQmpllai►ce �Idllns <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements p <br /> I I m <br /> Q Q 14 CCR§16459.1 (a)(b)(c)-Tire Program ID Number from CIW M8 <br /> Q 1 O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> ---- <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip togs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers # � lM EfffOfC�fll�ttt <br /> Q O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ` <br /> Q O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ! � <br /> O O Other: § '':/ i�/%i <br /> Comments does n 0 1 q eli eraf� V V a.sf,_ -,ire so I:zT h- l i 3'fis avt� <br /> hitQh �Iks Std' vi CeoL L� Cosilra r k1 be / [._i F'f ✓UCs�/ �L ���pnP.�r <br /> (20q) q(65 0433) <br /> Inspection Form Included: Q; <br /> Comments Included: C <br /> _ Business Reps Signature Phone Number sec or's nature Phone Number <br /> INSTRUCTIONS ON BACKLJO <br /> S :C� + E` ;F( ,qy P L E� f Z 3 62081 <br /> _ �7 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />