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-� Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rrr State of California <br /> -.13181(New 04/04) Survey Form - Page 1 $ - 1 6 0 6 6 0 6 <br /> California InteCgrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details. <br /> TPID- I I _ 0 ' Inspection Type (Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral .Q Observation <br /> Local (' If Referral,choose.referral type(Fill one) <br /> Identifier: S , jocko, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> Irl S M c C kt-c(j ej3 _ i <br /> Physical Address <br /> C l� <br /> /tis�� Inspection Date 0 9 � � �� � D .� <br /> 3 <br /> Time In Time Out <br /> Business Rep (� Title ®AM p7 O AM <br /> eOlQ[L✓ Bossa� ( I O PM , 07 V PM <br /> �Jy;ce �r�sio( <br /> Operational Status•Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ° 0 Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered �C <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - . Q Planned Q 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 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 O Other <br /> Part B-Inspection of Waste Tire Deader,Generator,Hauler and End-Use Facility <br /> �c1?, 61ir' �Y1'" 'M `5`L°a.,,ropTri�a �Fy,. , ' <br /> Q Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. ^.y'• <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ;) <br /> 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 /> Q Q 14 CCR§18459.3.-Retention of Manifest Forms and Tire Trip Logs for 3 years <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 •k,`*' <br /> Q Q 14 CCR,§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q Other.'§ // <br /> Comments ksnec*DYL f"D1i<DGv' <br /> - E <br /> isfie� ��rY�i��� l� ij5oyt (�a.i�'i`Ir hoolel2S Viewed InpOh Q, <br /> sf.a LzGg Aap A4_treS. hqJcc-"- omt 46-me, Ve,�iG'Ies ixa/44 <br /> Ar1 -,Ykc s aro1 velple • _A 3rclickwe <br /> Inspection Form Included:Q 1 f f��� * <br /> Comments Included: f/ 20R)L — <br /> us <br /> as Rep's Signature Phone Number ins ctoMs Ig ure.'c Phone Number, <br /> :R Mn ` 62081 <br /> INSTRUCTIONS ON BACK . ;_. K ,+� IRFLP L E 1112L3j <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0529204.0823 <br />