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�i Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> state CaliforniaSurvey Form - Page 1 1 1 - 1 0 1 3 7 4 4 <br /> cNVMB 781(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ` <br /> �� ��"""( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> t Inspected By Inspector <br /> C'�arkl� (T Po wef^ 3 q <br /> Physical Address <br /> 1 a � � �av►ol�.r bt I+ C:�r V <br /> a -e-cam 9 5 31? Inspection Date b 3 a p <br /> Time In Time Out <br /> Business Rep Title /' /� Q AM <br /> Puy 11 ' I J Q PM Z V O ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) q1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)I <br /> f 1 V ®Active 0 Passenger 40 Generator 0 Outdoor <br /> Latitude O 0 Closed 0 Altered <br /> GPS 0 Hauler 0 indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned ® T 0 End-Use •Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility i1 <br /> 00 PRC§42951-Waste Tire Hauler Registration and Transport of Tires �7 <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 <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 /> 0 0 Other: § <br /> Comments lh5 �e Stont'X,(Il_ vxs Fo, k0ct of <br /> p!Q, ramoyd dram -f�i5 c�(;�iz� il�n E�esi-� chafed 31ttol* <br /> Uimed• * 7if'e5 are- 5Uu.ot -rVlCzzt7w S�orv�erLiPfS. jT2s <br /> ova op ( <br /> Inspection Form Included:0 _ D `?9 <br /> Comments Included:0 -- <br /> w c � S/(L <br /> a;o s ep's Signature Phone Number In tor's nature Phone Number <br /> ■ INSTRUCTIONS ON BACK P lEA p:L 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0615104.0576 <br />