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ro� <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> C ,(tlewn4, Survey Form - Page 1 1 9 - 1 0 1 3 3 0 0 <br /> California Integratedgrated Waste Managegement 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 S 4f- O Routine ®Re-Inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Ste+ �' � L (i 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` �Y <br /> Inspected By Inspector <br /> DaI)t" ^sh47 <br /> Physical Address / Q <br /> 900 5' C_I �ka - <br /> / ^ Inspection Date <br /> W� sZ� Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Dii-.4 <br /> —- Operational Status Tire Type BusinessRoleStorage Type <br /> Tire Count(Whole/PTE) I -7s, <br /> ! S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ®Passenger 0 Generator ®Outdoor <br /> O 0 Closed O Altered <br /> GPS Latitude O Hauler ®indoor <br /> O O Inactive O Truck <br /> Longitude _ O Planned O OTR ®End-Use i O Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> ®Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture 0 Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer Generator,Hauler and End-Use FacilityM91 WIN <br /> r¢ z <br /> 0 O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 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 n <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days �x <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years 'n <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 /> O O :y <br /> 14 CCR§16462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 00 Other. § <br /> Comments <br /> Ot>� DI eGkutDwcoL e�.�•t..�{�S'�— -�rT"r t�-�.tll/i✓2,�✓ --/�"r��-n w�� GS'�-5 �r�► <br /> YK7+ <br /> Inspection Form Included:O b <br /> -D1 TZ <br /> Comments Included:O ` <br /> Bus ne Rep's Sig ature Phone Number clots Signature Phone Number <br /> INSTRUCTIONS ON BACK X, A P JLTE1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />