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= ,- Waste Tire Survey & Inspection Report,,..1a$pectionReport Number ■ <br /> rr state orCaVm is r J <br /> CIWMB 181(New ga,e4) Survey Form - Page I- � �1 9 - 1 d 0 6 7 6 8 <br /> California Integrated Waste Management Board <br /> Part A-Survey NOV 2 8 2005 BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details — <br /> TPID- 1 3 � � r, �j - O ' Inspection Type (Fill one) <br /> Site Suffix: `� D 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: av, �D �l� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 8 9 - <br /> 1-i 3b VV , 3C-D-tts W& <br /> Sh C D n C 5J,03 Inspection Date ( I / C) <br /> Time InTime Outr <br /> BusinessO VyRep ( Title n O AM O AM <br /> ✓trt O�IVatr� ®PM O 3 © S 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 5� (Fill one only) (Fill all that apply) (Pili all that apply) (Fill all that apply) <br /> ®Active ®Passenger a Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude _ Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all 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 �o W l <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. 3: 4 <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days ` <br /> "aue <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years a ' <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 <br /> Q 1 Q 1 Other: § k <br /> tf 1�� cgaz <br /> Comments �W Q A y-1 `S d- <br /> I efS . <br /> _ rctaswn <br /> 1-(,'•red r♦ vice.. -(iYe ,r W1 yec�V_ e 0QS_fr1 <br /> (J(IV1 I+�ro_l K �-J11[.4 Gc7�S ' �! c v� <br /> Inspection Form Included:Q ArdA) <br /> Comments Included:Q04 <br /> 1 r — '— `� ` 11& - 16� <br /> slness Rep's Sign t e Phone Number In --'a SI ure Phone Number <br /> O62081 <br /> ■.INSTRUCTIONS ON BACK x E ?€ JITiN1 P L E 1 Z <br /> a li c a� a ar c e n z.�,".y„ssatrsm . <br /> White Copy,CIWMB Yellow Copy:Operator Pink Copy.LEA <br /> 0600404.0801 <br />