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_i , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> t Slate of California <br /> C1WMB (Now oal <br /> California Integrated Waste Management Board Survey <br /> Form - Page 1 1 6 - 1 01 6373 <br /> Part-A.-Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 f1 2 Z - Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �T If Referral,choose referral type(Fill one) <br /> Identifier: N � Q CHP 0 CIWMB 0 Complaint 0 Educational Visit Q Other <br /> Business or Facility Name <br /> i ' Inspected 13y Inspector <br /> Physical A dress <br /> 316 A) Hwr99 <br /> `"A C150qo Inspection Date t Z,. I 3 G <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ' O PM O PM j <br /> D,f�+ �4r1 ha Operational Status Tire Type Business Role Storage Type Il <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply); <br /> f t &Active 0 Passenger 0 Generator 40 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 00 Inactive *Truck <br /> Longitude - I D End-Use i Q Container <br /> 0 Planned Q OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler Q Agriculture 0 Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENPaGJC � � 1 <br /> r <br /> `f W li ,tstQ Ai�4t1 N1 ►t�FI 'P RfiQl�tROMENTS / <br /> Of+fatlaaf` +�I# � t ' <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ; <br /> r <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle X✓ �' <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements jyt(p J <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program lD Number from CIWM$ ,� , <br /> Q 0 i 14 CCR§ 1$459.2.1 Submittal of Manifest Forms and Tire Trip Logs within 90 days ( Q377 <br /> N �� ` ��/,�'' <br /> 0 Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years -""""` "` ✓j' /` ;/ i� f <br /> 0 0 14 CCR§16460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461 Manifest System Requirements for Waste Tire End-Use Facilities <br /> . r�.^bks<.Ys'�s", �-.> ". ��/ �� ✓ <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § "`�'�'> i <br /> Comments J^9fzi � Ytci'`f b r G��./ (►'�tciK �c �1 F <br /> 04 — ?L+07�) t 4-(7-7 Lc, e, PA Ia-- Ave-, l/`�1 �s�-o Gl�j--35 t <br /> Inspectlon.Form Included: 0 Q <br /> Comments Included: 693t40 evei 7 ^Z�" <br /> Buslness Rep's ignature Phone Number Ins ct r s 1 nature Phone Number <br /> INSTRUCTIONS ON BACK 1 .� X �i. P t; 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />