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= , Inspection Report Number <br /> Waste Tire S. vey & Inspection Repo <br /> State of Bie1(New 04!04)California <br /> C11NMS u rvey Form - Page 1 1 2 - 1 01 4 8 2 6 <br /> California Integrated Waste Management Board <br /> PartA- Survey _ _ rnspectlon Details BLUE OR BLACK INK PEN <br /> Business Profile <br /> TPID- 2 Inspection Type (Fill one) <br /> Site Suffix: ` � 1 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral, choose referral type(Fill one) + <br /> Identifier: _ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> (�G�vI-- �� IA1 /� ' T' Inspected By Inspector <br /> +Physical Address y (JI�f,.i L Ll, l'C-�'�t'9^2 - t O <br /> - <br /> S Inspection Date T_ I l g I Qy <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> ' O PM Q PM <br /> Operational Status The TypeBusiness Role Storage Type 1 <br /> Tire Count (Whole/PTE) /,�,... +(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 10 Active 0 Passenger 0 Generator O Outdoor <br /> 0 <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> o? [Ive 0 Truck <br /> Longitude4 Planned 0 OTR O End-Use 0 Container <br /> - - - - -_ - I- - L -- 1 <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 0 Agriculture 0 Shredder 0 Other <br /> Part B inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> �•' - %al,. .'�;e,.x<-::. _ :�.'.i _ �ter• - /i, - ,i/..�'i � ri // /. <br /> %'Z.✓ w;:�� ,.irx. /'.iii".�`'%`%'.a..-/.T-./-' a;• /'-i � �:i / / <br /> E:yM,. s -�<.,�A .�.�3i. ..3Y1.:� �1� .,.. .;Rysp;..,i.<. r,� ,r.,.: y� s ,•s::; // � / <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> (� 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <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 years <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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 00 Other: § <br /> Comments Auo —. l w `�'� t ��,�-S Get-.fL�- ,.t.� �.. 5 a�Lr`4ly2-- <br /> Inspection Form (nciuded: 0 <br /> Comments Included: 0 --- '_�- �— 'ti—� <br /> _ in _ ature Phone Number I ector's Signa ure Phone Numberr� <br /> _ g _ <br /> OK V11; <br /> 620 <br /> 81 <br /> INSTRUCTIONS ON BACK �v'10ur P l- EI Z <br /> 'I'l 011 WON! <br /> White Copy:C1WM3 Yellow Copy:Operalor Pink Copy:LEA <br />