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Waste Tire Surv4y & Inspection Report inspection Report Number <br /> rIl- State of California <br /> CWMB grated 1st(Now Manage) Survey Form - Page 1 1 3 1 0 1 4 7 6 9 <br /> California Integrated Waste Management Board <br /> Part A- Sury y BLUE OR BLACK K INK PEN <br /> Business Profll Inspection Details <br /> TPID_ / Inspection Type (Fill one) <br /> Site Suffix: I (� 5 -3 t 10 o f Routine 0 Re-inspection O Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ,.� Jo �� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Fac lity Name <br /> q Inspected By Inspector <br /> PhyIca Addr4s 3 L J t> <br /> GA �5�� <br /> Inspection Date p � <br /> I <br /> I Time In Time Out <br /> Business Rep i Title Q AM Q AM <br /> QPM QPM <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 /> 1 Active O Passenger 0 Generator 0 Outdoor <br /> 0 Q Closed 0 Altered <br /> GPS Latit de O Hauler 0 Indoor <br /> O O Inactive 0 Truck <br /> Longitude — O Planned 0 OTR O End-Use 0 Container <br /> Business Type I(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 Deoler 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Statign 0 Hauler 0 Agriculture 0 Shredder (a Othert1a <br /> f <br /> Part B - Insp 'ction of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFQRCI ST T , <br /> V ;;A Ij HA► _ NG AND MAA ST REQUIREMENTS <br /> O 1 OO Nutic�C1t yto)�ikn �il�rt <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. �� � j <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O , <br /> 14 CC §18459 -Responsible Entities Complying with Manifesting Requirements3lftq <br /> .� <br /> O 0li 14 CC §18459.1 (a)(b)(c)-Tire Program 1D Number from C1WM0IV 0 <br /> , <br /> O O 14 CCk§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCk§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O ' 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities NI, / <br /> O O <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § ' <br /> Comments <br /> 5rv.a fn i.t sr b� C>� hyo�,�w- -�I i'`4-S <a VV-0 - <br /> e;l _�_ _ 4 Sf14r_. SG is �✓q5 �j' - <br /> C.0 <br /> licy- *V 11"te•,-G10e- <br /> Inspection FormIncluded: 0 IJ <br /> )66 --LComments Included: 0 — 33 `� rD <br /> � <br /> ness Rep's Signature Phone Number Ins is Sig ture Phone Number <br /> INSTRUCTIONS ON BACK [lli*� f1 F L � f 3 62os1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />