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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> ClWMB astew04/04) Survey Form Page 1 15 1 0 1 3 4 7 5 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details <br /> TPID- / - Q Inspection Type (Fill one) <br /> Site Suffix: <br /> I *Routine Q Re-inspection Q Referral Q ObserI <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: Qti �/`irJQ <br /> ��''h � Q CHP Q CIWMB Q Complaint Q Educational Visit Q <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> • �rc� iso� �i �-�+ , 1�� / <br /> Physical Address 3 9 - ( 0 <br /> a9oz/ 164:1,�gr Z-1Z - T� <br /> Inspection Date Lo <br /> Time In Time Out <br /> Business Resp Title AM M <br /> O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) p (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( 0 Active Q Passenger *Generator 0 Outdoor <br /> Closed Q Altered <br /> GPS Latitude O Q ClQ Hauler 0 Indoor <br /> O Q Inactive 0 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 Q Government Q Retires 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 0 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-Registration/Decai in Vehicle r- <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB ° rY <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days r w, <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years y <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 s` <br /> Q 1 Q 1 Other. § <br /> Comments AC <br /> 4".4- 4111le&"y G�ILc/ Gk�G� o•�Q�ui uJc?� <br /> �d ; /�°n�ako.z %:/`c /'t?u•..orrcs cyQ�{c 4...cae /?.ccr�-Q1 �%^�s <br /> au,'? l lei^tui-r�C rc�,o,t �+e �• 7�fi '� 9 wrJ <br /> Of, �C . <(/ 1�i r e SOC f e sQi alIMP y <br /> Inspection Form Include <br /> Comments In 11+,it <br /> IB -ins ss Rep's Signature _ Phone Number Inspector's Signature Phone Number. <br /> ■ INSTRUCTIONS O BACK ' r ~, XIA Ak P E�1 3 62081 <br /> -� - ® ■ <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy LEA <br /> 96151.04.0426 <br />