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GG <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> state of Survey Form - Page 1 17 - 1 0 3 3 5 3 <br /> CIWMBMS1818041 <br /> 1 tew 04) <br /> California Integrated Wasto Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: I T D 5 11*Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sq3p,��G/� E/jf, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> /c?5 l,J �, ,ks� 124 - <br /> Inspection Date <br /> 4-�k-fes G{� zi 1 17 <br /> Time In Time Out <br /> Business Rep Title_r AM O AM <br /> St=v� (�Cs'c'�. b t ru;I"m •PM O PM <br /> r <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> The Count(Whole/PTE) t / D O <br /> ®Active 0 Passenger ®Generator 0 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 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires 4 <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O 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 K . <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 /> O 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 O :. <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generatorsto 1 <br /> 0 Other: § 2 - <br /> Comments <br /> F.scrrl-. ��� el� 4 ic- np, a-jrra +;re-5 <br /> I l L ��- 1') <br /> W 1�j0� W�G�TY'[ �t/I Y�4 N' t�A3`►7L �IM'�S � 1 4R CJI�'C� <br /> G.t_y. r LLQ�.J`G� L✓a3 /'+- A 1 R rs O <br /> Inspection Form Included:0': <br /> Comments Included:0 <br /> Bust ss ep's Signature Phone Number Inspe or's Ignature r wPhone Number <br /> INSTRUCTIONS ON BACK ( 3 62081 <br /> ■ White Copy CIWMB Yello Copy.Op3ralor Pink Copy:LEA © ■ <br /> G1r.05204.0524 <br />