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€5 Waste Tire Survey & Inspection Report inspection Report Number . <br /> r State B 181 IN- <br /> 1 4 - 1 0 0 6 4 2 9 <br /> Cgrated Mete <br /> emanage) Survey Form - Page 1 <br /> California Integrated Waste Management Board - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - <br /> --- <br /> TPID- Inspection Type (Fill one) <br /> Site.Suffix: 3 O ' IQ Routine Q Re-inspection Q Referral Q Observation <br /> Local ; If Referral,choose referral type(Fill one) <br /> IdentlFler: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AddressLACIM <br /> ~— I <br /> I. _l <br /> Inspection DaterA <br /> Time In Time Out <br /> M O AM <br /> B=_sinevs�s�lRe `p Title O A ? O PM <br /> 4 � - e� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whble/PTE): (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active 0 Passenger Q Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive p Truck <br /> Longitude - Q Planned 0 OTR Q 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 0 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 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility .. d' <br /> c <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle �M <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 COR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18458.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days _ zc. <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O Other: <br /> Comments 'F <br /> .e. <br /> dCOeSyViT s[G ..,�� <br /> r N <br /> Inspection Form Included:Q <br /> Comments Included:Q - -- 9-'Z7, 76`�D­ <br /> Business Rep's Signature Phone Number pct gnatur Phone Number <br /> 'Y �` 62081 <br /> ■ INSTRUCTIONS ON BACK Q* % - {. l p L. E 111EA <br /> While Copy.CIWMB Yellow Copy.Operator -Pink Copy:LFA ® ■ <br /> 0525804.0142 <br />