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ttt <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> State of California <br /> gratedW sNew 04104) Survey Form - Page 1 i 5 1 0 1 3 6 5 7 <br /> California Integrated Waste Management board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- / - O ` IRoutine nspection Type (Fill one) <br /> Site suffix: f� O ( <br /> `-' / � Q Re-inspection Q Referral Q Observation <br /> Local / _ If Referral,choose referral type(Fill one) <br /> Identifier: SQ,K d.1Q L.t��y ( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name C/ - <br /> Inspected By Inspector <br /> i>ze n r�z.z /Z'Let�+CSC �ed�oyr Se_ <br /> Physical Address <br /> �Ltr3,Lio%If/1 F-tJdi� <br /> -Z '7 �r - <br /> J_ ' �5 Inspection Date 09 <br /> Time In Time Out <br /> Business//Rep Title •AM Z AM <br /> 98 O r 0 P `7 0 P <br /> - — — - Operational StatusTire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ' . 0 Active ®Passenger •Generator Q Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> Q Hauler ®Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> i <br /> Business Type (Fill ail that apply) <br /> Q New Tire Dealer Q 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 Q Agriculture Q Shredder Other <br /> I _ <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility EhtfNT''SfiATtB74 <br /> } P. _ <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires ,Q NotieeOf Violation 0,ExfensioR.;< <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 'GornpJiag4e,Dead iine <br /> Q QPRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB % yi <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 = __ <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities . <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators E KM <br /> O Q <br /> Other: § <br /> Comments lL.0 ;h,j wz ?41.,'r <br /> 41 rs•� <br /> K( �IF'rf'1�1 1/r icrl[W 161e) <br /> Inspection Form Included: 0 <br /> Comments included:Q 'T/� <br /> usmess Rep s Slgnaturdr Phone Number Inspector's Signature. Phone Number <br /> ■ INSTRUCTIONS ON BACK " ' fy al1XIAIMIPILIE1 1112131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LFJI <br />