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Waste Tire Survey & Inspection Report p p <br /> "i. Inspection Report Number <br /> State of California <br /> CIWMasew 04)4) Survey Form - Page 1 1 1 0 1 4 8 4 Q <br /> CaliforniaCaliforniaIntegrateddW Wastte Management Board <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detags <br /> TPID- ` J Z C` - Inspection Type (Fill one) — <br /> Site Suffix: " 4j Routine. Q Re-inspection Q Referral. Q Observation <br /> Localp � >� If Referral,choose referral type(Fill one) <br /> Identifier. �(yt,N J 1 Lc7tJ� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address Zj - l IJ <br /> 1 Inspection Date / Q <br /> f.�t.�b� CJS �5-cp � <br /> Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> ~ \ -L D �_'> ® PM "'D ` b b ®PM <br /> �l C\N&'M�� �0 V"r c - <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 /> t ' ®Active ®Passenger ®Generator. 0 Outdoor <br /> O Q Closed Q Altered <br /> Ca�S Latitude �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 /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Retreader Q Dismantler Q Tire Derived Fuel <br /> ®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 /> � k� 7p ���j'A'� �.i�.p,��pe � ,i- r'' .a U '��,-'�•IR a :� � .g.µ3* x <br /> .,. :, y��.74���T"'�"4��-n �'_--'^�ry���,�64n� �.�3�;3Mti.. T'• .:may' 1.. N ��. 'do-'Y �{ 'C,� <br /> Q I ® PRC'j42951-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/Decal in Vehicle <br /> Q Q 14 CCR§18459.-Responsible Entities Complying with Manifesting Requirements s a <br /> 0. Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q .0 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 azs <br /> •� •^�. � +� fib. <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> o- <br /> Q Q 14 CCR§18462-,Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments <br /> �tMIR w(4452 '9\X A95- scr - <br /> 171M r VtTSZ \ r7�5 .LOyrt l \ Enterb <br /> .w- <br /> L� KB L <br /> Inspection form Included:Q <br /> Comments Included:Q " `' O — <br /> Husfriess Rep's Signature Phone Number Ins actor's Signature -Phone Number <br /> ■ INSTRUCTIONS ON BACK A j'tA p I: ii 1 Z 31 6208.1 <br /> White Copy CIWMB Yellow Copy Operator Pink Copy:LEA © ■ <br /> 0529204. 1060 <br />