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�i Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate of California Survey Form - Page 1 1 4 - 1 0 G 2 ■ <br /> CIWMB 18 y 4(New 04/04) <br /> California Inlegrsted Waste Management Board J <br /> Part A-Survey __ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> i TPIp / ii, 0 / 0 - 0 / Inspection Type (Fill one) <br /> Site suffix: 7 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local /+ If Referral,choose referral type(Fill one)' <br /> Identifier: `A►',{, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name UInspected By Inspector <br /> &L'ld is Q►,r a-?( 7Ire <br /> Physical Address <br /> q00 S r C rc7�ee — <br /> OIL 0"If G�5a L)a Inspection Date 3 / L0 / 1> <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> �• _ �' i, ' 6 �veeiraPM O PM <br /> Operational Status Tire Typp e Business Role Storage Type <br /> Tire Count(Whole/PTE) I t D (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger ®Generator ®Outdoor <br /> Latitude <br /> Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> a New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived— Fuel <br /> 40 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q 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 u <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 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 'V <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days '-�•;: <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ` �• µ 7 ` <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers fl. <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities z R <br /> M <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators _ <br /> Q Q Other: § <br /> Comments <br /> D'+ MpeQ wADx &s date,—J _ 6ll CSntqd <br /> r 7u <br /> US(d *eS7OM KJP-W and kifibl d=- Cs J <br /> - <br /> wayYDIs a �bT s ✓ ewcd, total -Ye apw' � qs&4 `torts F&- <br /> &k om d s-v6ed 'h sAqp, AJo d;zl/q `ox s Aofzed, <br /> Inspection Form Included:O ��O p,�"� a f� <br /> Comments Included: -- —`�k_19 --- <br /> ��(I�u . ss Rep's Signature Phone Number Insp�dets Sig e Phone N�mbV <br /> INSTRUCTIONS ON BACK )MINN.� - n 62081 <br /> � � xArPIL E -TiII <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0708104.0083 <br />