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Waste Tire Survey & Inspection Report Inspection Report Number <br /> r State of California Survey Form - Page 1 1 5 - 1 Q 1 Q $ 0 3 <br /> CNYMB 181 flew nage <br /> California Integrated Waate Management Board <br /> P_ artA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID- e O 6 - Inspection Type (Fill one) <br /> Site Suffix: i ®Routine Q Re-inspection 0 Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> identifier: a y� QQf��)1 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> BusineThss .Facility Name OO ' Inspected By Inspector <br /> r , _ _ <br /> Physical Address 3 d � <br /> o2rs'3 3 /j// <br /> Inspection Date / Q a 07 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> v_ n10-411/t A� ��� O PM Q PM <br /> /t-�LWJ /�/ Operational Status Tire TypeBusiness Role Storage Tyke <br /> Tire Count(Whole/PTE) 3 0 (Fill one only) (FIA all that apply) (Fill all that apply) (Fill all that apply) <br /> r ' 0 Active !Passenger ®Generator (P Outdoor <br /> O 0 Closed O Altered <br /> GPS Latitude Q Hauler QIndoor <br /> O 0 Inactive O Truck <br /> Longitude - Q Planned O OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer A Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuei <br /> O Used Tire Dealer Q Auto Body O Car Dealer 0 Collection O Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 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 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 101 Q 1 Other: § <br /> Comments <br /> �'es*/rc✓ ufio.� � url`. -0 u/aelee <br /> Inspection Form Included:Q <br /> Comments Included:Q G✓L 1��1 i <br /> ess Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK 1EVAIMIPIL El 111213 62081 <br /> 0 0716504.0034 White Copy:CIWMS Yellow Copy;Operator Pink Copy:LEA ® 0 <br />