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rar <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r State of California <br /> C <br /> rated astew-ge Survey Form - Page 1 ( 8 . 1 0 3 6 2 <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: 0 *Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ('�� HReferral,choose referral type(Fill one) <br /> Identifier: J n 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address //�� 3 9 � 'V / S 6,80 7-,V4004 <br /> 2 211.10 I&e — - <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title / 10 AMAM <br /> Q PM / 'L'- O PM <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 /> Tire Count(Whole/PTE) f <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 �1� <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 0 Other <br /> Part B-Inspection of Waste Tire Dealer Generator,Hauler and End-Use Facility <br /> % t < <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 O <br /> 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 ` <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days - <br /> i <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § e <br /> Comments a�°! c Dr jaA/'C w <br /> o f 4,Ce q�r< WW-& dose. �/ p�PPE /0'). /�!. ire tea,, 9 <br /> / 947�dy tet- xcw'�� r'� v4e -Pk! 4qe Q rid <br /> ma'i v4t -tea! '0ia.-I Co ou der 3 <br /> / C <br /> Inspection Form Included:0 t� p <br /> Comments Included:0 `sl -( <br /> siness Rap's ignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK E RRMPILIE1 1112F3] 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0622104.002$ <br />