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Fi Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of Cal <br /> 'rfornla Survey Form - Page 1 1 1 - 10 0 6 7 7 2 <br /> CNVMB 181(New OMq. <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ^ y n Inspection Type (Fill one) <br /> Site Suffix: 3 5 9 o Routine Q Re-inspection Q Referral Q Observation <br /> Local (� 1 If Referral,choose referral type(Fill one) <br /> Identifier: ` y� JvKy��Y( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 7�,J Inspected By Inspector <br /> Tt�s-tat� &cre,fe �'' 1°r`�f 3 q - / o / <br /> Physical Address <br /> 0/go VOLU S(t o Cf, <br /> y�r NM10 C4 Inspection Date / I D O 5` <br /> rL Time In Time Out <br /> Business Rep Title r ®AM / O AM <br /> C _ �' QPM ` -3 D 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 /> Active Q Passenger #Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude li Q Hauler 0 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 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 /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <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 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 /> 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§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators � � i9i y'IClif ?I� 9t4141� <br /> 1010 I Other: § t 1 <br /> Comments - v <br /> � 1,(l�rlc VlpcZ Ly <br /> LL klas no�eof� f Is.�eef- aF Jrk�.s at_Uses TtY?- c.<LsEd <br /> aid VjkSfe_' e-5 ,dor r4reac t or A-SpDsd_ a 1nJo)ces viewed <br /> Un tt2S-'a t/I a l� fg On Sl+p- A:rp, qtead S <br /> Inspection Form Included:Q <br /> Comments Included: <br /> q83-3097�/tnn� _1 - 1,7(06 <br /> Busin s Rep's Slgn tura Phone Number +1n .ct®r'jSIgn.ture Phone Number <br /> INSTRUCTIONS ON BACK E A M P I E 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0533504.0075 <br />