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=_ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 18asteManage) Survey Form - Page 1 <br /> Callfomla Integrated Waste Management Board <br /> Part A-Survey BLUE ORB_LACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- Inspection Type (Fill one) <br /> Site Suffix: 7 y p v / *Routine Q Re-inspection 0 Referral Q Observation <br /> Local / , If Referral,choose referral type(Fill one) <br /> Identifier: Sirt d1pQ y — 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> n Inspected By Inspector <br /> Physical Address 3 , ( - f o / <br /> 4.13J3oa'-�%�LA. <br /> /a so 7'! , d, S_f< <br /> Inspection Date v/ <br /> Time In Time Out <br /> Business Rep Title 0AM <br /> O PM / ®AM <br /> ( / O PM <br /> - / Operational Status Tire 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 /> ' f ®Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ` Q Indoor <br /> 0 I)Inactive O Truck <br /> Longitude - 0 Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder •Other _/- <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ffO�RCE"MENTSTATUS` 77 <br /> HAULING AIV"ANIFEST REQ#JtI g"NTS Notice Of Vioiatian <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires L Extension <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirementst rf til- <br /> 0 <br /> Q 0_ 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB "Ell / r <br /> Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days 4?•' <br /> Y. <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O ,. . <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § " <br /> Comments ham% ,1.- `),4*.'p &0.74��,44.6P 0, - S►GP'c ilJ�e / a <br /> ~rc <br /> ye, <br /> Go <br /> Of _r,-,2f 3 ,rt rn <br /> Inspection Form Include <br /> Comments Includ20 3o '" f,� r ws <br /> Buslnes p's St Lure Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK 10XIAllill i , 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0628404.0073 <br />