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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r State of California <br /> C'g2ed B,steZanage> Survey Form - Page 1 1 2 - 1 01 3 6 5 4 <br /> Calitomia Integrated Waste Management Board <br /> Part A.SurVe_ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O n Inspection Type (Fill one) <br /> Site Suffix: O - V Routine 0 Re-inspection 0 Referral 0 Observation <br /> Locall/� If Referral,choose referral type(Fill one) <br /> Identifier: Jc�y cJ(jQ <br /> B0 CHP Q CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> us/i>ness or Facility Name <br /> /n Inspected BY— / 0 / Inspector <br /> /� <br /> Physical Address L 3 9 <br /> Sue eo:�v��r. <br /> Inspection Date O , 8 0 6 <br /> Time In Time Out <br /> BusinesR(p�` arl7 �n�o TitleJlJ1�sssA�,� O AM ®AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> ` <br /> Tire Count(Whole/PTE) ^ V (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f t �2/.O <br /> Active Passenger 1 4D Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude I 0 Hauler 0 Indoor <br /> O 0 Inactive ®Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type.(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler .Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer Generator Hauler and End Use Facility <br /> ON <br /> 0 0 PRC§42951`-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. 4 <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements y <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 <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 yearsY <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 Facilitles 4 <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> b - <br /> 0 0 Other. § <br /> Comments 'AC <br /> Akee'&'y <br /> ow. 3 <- .r . /1/0 N,ore4, s 01.,f <br /> Inspection Form Included:0c/'%1 ' , // / —9�4 e f <br /> 2o9-41h6 3003 y c�+^}' 4! 0 <br /> Comments Included:0 - --- <br /> Business <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPI 62081 <br /> ■ Nhlte Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0622804.0427 <br />