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aea <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> a 8t ate of California <br /> ClWMB asteManag) Survey Form - Page 1 1 7 - 1 01 0 6 6 6 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� �� /� - © �j Inspection Type (Fill one) <br /> Site Suffix: ® l r, 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalnI^ 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 /> ��I �C Inspected By /� Inspector /�' <br /> Physical Addr� l rw aJ 9 _ I 0 I JAPL'+ 17`yJz& <br /> -Ra�� ^ ,� Inspection Date D � � � y <br /> (l/'/I} Time In Time Out <br /> Business Rep ` Title O AM O AM <br /> Gl Y� tr eYQ1. 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 /> t 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer •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 /> f '�t ( Fac 1 3 " ? <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 00 PRC§42953-Contracts with Registered Waste Tire Haulers. A <br /> 0 0 � <br /> PRC§42956-Registration/Decal in Vehicle 7 <br /> oz's' <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements s <br /> 0 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 r t <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities z <br /> 0 ® 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> t <br /> 0 0 then. <br /> t ` r t�.X.6.� •Wr . ` , ` <br /> Comments , <br /> c <br /> Tlr.0 Ae- ire d 3 a&L mp,-H, . - <br /> �� e �i r ast �Sa.Ps au�cl 1 ins cfi�x. <br /> Inspection Form Included:0 !� ' <br /> Comments Included:0 -— , - <br /> _ Busine ep Signature Phone Number In ct is Sig, re hone Number <br /> INSTRUCTIONS ON BACK162081 <br /> k ���� `� � ?� R AA P L E, <br /> ■ While Copy:CIWMB Yellow Copy.oDeralof Pink Copy:LFI{ ® . <br /> A711604.0158 <br />