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tt��1 <br /> Waste Tire Su 'y & Inspection Report Inspection Report Number <br /> State ofC ( Survey Form Page 1 l - U 0 $ 4 <br /> CIWMB 1t311(NewNow 04104) <br /> California Integrated Waste Management Board <br /> 13 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I ! d ( jo Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Lo dj Hors cx at <br /> Physical Address 3 — D �✓re- �q 5 <br /> Inspection Date <br /> 06 © I 0 c(- <br /> Time In Time Out <br /> Business Rep Titlen�1 - O AM O AM <br /> f�r'�S/ tai dr- O PM y 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 /> © 4 Active *Passenger *Generator 11 <br /> Outdoor <br /> 0 ! Q Closed Q Altered GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — O End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> i Q New]-ire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Al Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFCt, )Vll„ N 7 ,T ?'gg , <br /> V A I HAULIN4 AND-MANIFEST(REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q y9tYtrg.Qf �13f1g #ftk <br /> / <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. COt1lplliMgti 174al1i)h� r,: i <br /> O 1 O 1 PRC§42956-Registration/Decal in Vehicle f <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DAto <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years '""' <br /> O O 14 CCR18460.2-Manifest stem Requirements for Registered Waste Tire Haulers (� / <br /> § fS t <br /> Y q 9� <br /> O O ,� //✓ <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O <br /> O <br /> 14 CC§§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O y <br /> Other: / x: In <br /> Comments r�iGl 11 �y IIA 5G5S A elf— <br /> �� D . �N;-mss ✓ -�© ,�� -f-it a. -��i n � ok,L .. <br /> r� 1lnda L-x,54� Coe le,,— <br /> %� - <br /> Inspection Form Included: Q // 17G / <br /> Comments Included: Q �. � l 5347 <br /> ),41n&p't Signature Phone Number ctor's Signa re Phone Number <br /> 2L INSTRUCTIONS ON BACK �£ `-ICK. I:'X R � P L11M. 23 62081 <br /> . i <br /> While Copy: IW MB Yellow Copy:Operator Pink Copy:LEA <br />