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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> "r CLMa8�`(Nw04104) Survey Form - Page 1 I 1 Q 1 Q V <br /> califomis Integrated ts Waste Management Boa <br /> Part A-Surve --- -_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Sufflx: 1 3 O ' 00 Routine Q Re-Inspection Q Referral Q Observation <br /> Localc^,n If Referral,choose referral type(Fill one) <br /> Identifier: Qa ,i r O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Businessor Fpcility Name T <br /> QJl Inspected By Inspector <br /> RW, Cn <br /> Physical Address C) <br /> 5-Do /\J. C f Lir <br /> 0(1t Gf 07 155,�Y© Inspection Date C) / 3 / O <br /> Time In Time Out <br /> Business Ref,, Title O AM O AM <br /> UOhrli f sky -- a-4 -�y�n O PM O PM <br /> Operational Status Tire TypeBusiness Role Storage Type. <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ®Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed O Altered <br /> Latitude <br /> GP$ Q Hauler Q Indoor i ' <br /> O �Inactive 0 Truck /V <br /> Longitude — 0 Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 0 Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer 0 Collection Q Crumb Rubber � ` <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other (�� " � aid <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Ob 5 e$ <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O . <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 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 r <br /> () O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 ! O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 10 O Other: § _'..'n <br /> Comments 'pIn7I}ht )"speech' ► tf,�S ckah, A ilowinq eVas fibbed `o <br /> CI Lkc,► se S U Sch K" .D CVs oe yQ.9te -fires as P-epoAr or <br /> _ u'+c�. is hee c1 . No �a�cies Franc► CaS�- I� +. No iblct ro►�s <br /> Kd r - <br /> Inspection Form Included: QI <br /> Comments Included:Q "���I) <br /> usine ep's S' nature Phone Number I sp ctor's �na'tu�re Phone Number <br /> INSTRUCTIONS ON BACK T X R h 1L1E11112131 62081 <br /> ■ NO <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0710-5-904.0332 <br />