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J <br /> ATfomia <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> #tale rCal Nornia 04/04) <br /> Survey Form - Page 1 I $ - 1 d 0 6 6 Z 2 <br /> tegrated asteManage <br /> Integrated Waste Management Board - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> ..�BusinessProfile _,-- Inspflcttnat2etalls_ <br /> TPID- — — ' Inspection Type (Fill one) { <br /> Site Suffix: �77 4�_ ®Routine Q Re-inspection Q ReferralQ Observation <br /> - — <br /> LocalI s f . If Referral,choose referral type(Fill one) <br /> Identifier: 1Sp`� ��� IAI l,dJ�nti Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ( v'C—,A_ il,' � I I i <br /> Ph sical Address - - <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ^ l ®PM o C> ®PM <br /> Operational Status Tire Type Business Role Storage Type' <br /> Tire Count(Whole/PTE) \ ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger Generator I&Outdoor <br /> O Q Closed Q Altered <br /> Latitude <br /> GP$ Q Hauler Q Indoor <br /> O Q Inactive .Q Truck <br /> Longitude _ Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel - <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection p Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q ® 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB ;- <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q <br /> 14 CCR§78459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q .0 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 <br /> 1.0 1 Q Other: § <br /> Comments CMnYL.�--� <br /> t_S v v.•�, <br /> �txr y`Z�(„ � �, 015� wwg�ti \Ltr"l. �t•LVt-wt* � l 1`LD r7S <br /> u.-�r.c_ tl tl C5 <br /> Inspection Form Included:-Q <br /> Comments Included:Q �20Q)�5- isI5 <br /> Business Rep's Signature Phone Number In pector's Signature Phone Number <br /> v. 62081 <br /> INSTRUCTIONS ON BACK I Correet Incorrect �/ r A' P " <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0525804.0151 <br />