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Waste Tire Survey & Inspection Reporh Inspection Report Number ■ <br /> iiStat e or caurornia <br /> CIWMB 181(New t,aqe) Survey Form - Page 1 ``'7 -F1006794 <br /> California Integrated Waste Manaycment Board <br /> Part A-Surve _ EC 13 LUE OR BLACK INK PEN <br /> Business Profile- Inspection Details <br /> TPID- _ ' Inspection Type(Fill one) <br /> Site Suffix: 10 Routine Q Re-inspection 0 Referral 0 Observation <br /> LocalcG If Referral,choose referral type(Fill one) <br /> Identifier: —10 ��(,t,� C� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> NL,- Ca Foods , Tnc. <br /> Physical Address <br /> �?a0 <br /> o� 1 L�� Inspection Date <br /> ( Ca q / t <br /> Time In Time Out <br /> Business Rep Title D S-O AM S O AM <br /> ' �PM IPM <br /> J � h� Cd��_ �/ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) fie-- (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> l7 •Active 0 Passenger f Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ®Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ®Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ' r ' <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements f <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 1010 1 Other: § <br /> Comments r r �aLlourz t *S <br /> �as fr�cc�ina f=1e - OF 31:5 � ma8� 4 �iftS Seryi CA4 64, <br /> r b' n Y heel . Q.+t� 1�naf' i -A0'"i 2Ae_ <br /> ro- &wo1QQQ, A Cis arm <br /> 2� <br /> Inspection Form Included: -y� q rn <br /> Comments Included:O !'� �d��x O - 1W "��"' <br /> slness Rep's Signature Phone Number. Inspe or's St lure Phone Number <br /> INSTRUCTIONS ON BACKP L B 2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0E.Ok-D404.Et53'1 <br />