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F:d <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> rrr Integratstateorcanfomla Survey Form - Page 1 1 3 - 1 0 1 0 7 8 4 <br /> CIWMBed 1WSt(New <br /> Californmage <br /> ment Board <br /> ia aste Manage <br /> Part A-Survey - _ BLUE OR BLACK INK PEN <br /> Business ProfileInspection Detil is <br /> TPI - <br /> Site Suffix: j C� r - O j. Inspection Type (Fill one) <br /> Site 'j (� ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. SOLA-✓�v`Z l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name LJ - <br /> 61-aptck Inspected By Inspector <br /> Physical Address 3 ( Q / \Jp,�t y Fias-o- <br /> Tra c.(/�J C'� /� Inspection Date <br /> Time In Time Out <br /> Business Rep r Title Q AM O AM <br /> V GZr �J�e I�C K� �(/ O PM QPM <br /> Operational.Status The 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 /> r r Q Active Q Passenger Q Generator Q Outdoor <br /> O ®Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> -Waste Tire Hauler Registration and Transport of TiresQ Q PRC 42951 <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements , <br /> Q O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB s <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 <br /> Q Q 14 CCR§1 B462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § •MG,e`Ln r <br /> Comments %KS �:�Z�t7Y► ` S dal/C '/(c`S is Q!°L !M U 106,r S/b�f <br /> Inspection Form Included:Q Q <br /> Comments Included:Q - 7 J/ <br /> Business R p'pWnature one Number In a rs Sig ture Phone Number _ <br /> ■ INSTRUCTIONS ON BACKr il <br /> EXAMPt62081� 123 © ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br /> 0719304.0027 <br />