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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> Cgrated Waste <br /> Survey Form - Page 1 1 9 - 1008082 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: 1 3 2— - C r Q Routine ®Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: , �k;, i`-�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> nInspected By Inspector <br /> Fr�ecl 1, <br /> Physical A dress <br /> Inspection Date <br /> �J j�i�•�� Time In Time Out <br /> Business Rep f Titllec� O AM O AM <br /> �✓fj�, C/hlrQ.✓ O PM O 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 I® Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude � Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer m Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler n Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFQRCEMENT.STATJS <br /> V A 1 HAULING AND MANTEST REQUIREMENTS Q Nt7tice UP Vialatl�n Q' �pna(An <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers, Compliance Iaadllite <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date /.:LD <br /> l <br /> O Q 14 CCR§18459.1 (a)(b)(c)-Tire Program l0 Number from ClWMB L] <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requlrpd fAt NOS 9rl1 <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q : 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q f(afeprAi)I1V)lI�I�3� �4fa7�Tl�n� <br /> Q Q 14 CCR§ 18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br /> ----T^ --,<m.-�rac,e>!,.,,4iic In^s'ly'/�•'i;," <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § �:Ifl �S�Ix��tJB��'-�����i - h.•.. <br /> Comments I'C7_34 � ver �l e� a 1 J//4 -hvi <br /> pl,,� ll r�lam,�t�►.-.� <br /> Inspection Form Included: QI 1 L <br /> 7T, <br /> Comments Included: Q`Busl ep-s u Phone Number ors gn a Phone Number <br /> INSTRUCTIONS ON BACK Carre Inc `meat; r f 'M E A icy P � � ; ; ; 62081 <br /> White Copy: IWMellaw Copy Operator Pink Copy'LEA <br />