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�67r Waste Tire Survey & Inspection Report Inspection Report Number �. <br /> State of CalHornla Survey:Fo.rm - Page 1 6 - 1006 4 l <br /> CNJMB 181(New W04) <br /> Califomia Integrated Waste Management Board .._. _ <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Bustriess profile lnspectioa<Detalls <br /> TPID- _ I q Inspection Type (Fill one) <br /> Site Suffix ( 1 :L $ •Z C. ; `� 0 Routine Q Re-inspection Q Referral Q Observation <br /> L.W If Referral,choose referral type Fill one <br /> Identifier Q CHP Q CIWMB .0 Complaint' Q Educational Visit Q Other <br /> Business or:Facility Name Inspected By Inspector <br /> (-5- <br /> Physical <br /> Ph sical Address <br /> M1 ecr pe - <br /> -f <br /> Ins ction Date <br /> City 7 � !�!S � �JS <br /> City ;rate irp Code Time e_In Time Out <br /> Business Rep Title ( + AM ;— Q AM <br /> 1/1O PM �'f O PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 6 (Fill one only): (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r o ®Active Q Passenger ®Generator A Outdoor <br /> - -- O I Q Closed Q Altered GPS Latitude O Hauler Q Indoor <br /> O II O Inactive *Truck <br /> Longitude - 1 O Planned Q OTR O End-Use 0-Container <br /> Business Type:(Flllallthat apply) <br /> 0 New Tire Dealer Q Auto Repair. Trucking Fleet. O 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 O Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. x `' <br /> 0 0 'PRC§42956-Registration/Decal In Vehicle <br /> 0 O 14 CCR§16459 -Responsible Entities Complying with Manifesting Requirements <br /> O Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O ` �. <br /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days - <br /> 0 O 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 O 14 CCR§18461-Manifest System Requirements for Waste Tire End•Use Facilities <br /> 14 CCR 18462 Manifest System.Requirements for Tire Dealers or Waste.Tire Generators 4. <br /> Q` § Y q <br /> Other: <br /> Comments A— A a 5� F5 XA P S. <br /> 11 -- <br /> Inspection Form Included:Q <br /> _ - y53 768 <br /> Comments Included:0 <br /> Ina ss Rep' i nature Phone Number Ins iPhone Number.. <br /> INSTRUCTIONS ON BACK of 1EVAIMIPILI 62061 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 0525804.0165 <br />