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SEP-10-2004 11 : 13 AM MIDAS. AUTO. SERVICE 2093699430 P• 02 <br /> Waste Tire S . i Inns tion <br /> ey � �t1S�eCtlOr1 Report L <br /> � Report Number _ <br /> MCA of Calllarnta - <br /> °'�at81(NOW°°t° Survey Form - Page 1l 7 . 1�0 _0 8 0 01 <br /> Cellfvtnie Intaprated Wasty OAanapement Board 9 —__._----„,-•-.._. �� <br /> Part A-Svrve BLUE�OR BLACK INK PEN <br /> TPiD• T. <br /> ». 1 ) ��� Inspection Type (Fill one)` <br /> Site 9ufflx; G � <br /> i_ J Routine O Repeclion O Referral t0 Observation <br /> Lolel <br /> Identifier; �~ If Referral,choose referral type(Fill ono) <br /> `--.��� ff. O GHP <br /> r � ...... Y•t� Q CIWMD O Complaint O Educational Visit O Other <br /> i Business or Facility Name <br /> Inspected By Inspector <br /> �j✓✓ <br /> Physical : f � .. l <br /> S , � I � _ I f i j ! •r✓I► .e�...r� � i <br /> ' 1 I � ,J nrr •-, <br /> _s — --— — <br /> 1 <br /> 6 <br /> inspection Date / <br /> I L <br /> [ ry. ................_....- ", ii'. f Time In Time Out _ <br /> tusiness Rep Title f...._...... ..- <br /> jj� I f <br /> O nM O AM <br /> /''� • O PM O PM <br /> Operational Status Business Role <br /> I <br /> 2 ((Till ane only) (Fill all that apply) <br /> Active ®Generator <br /> I�J1..l ll,I I,,,s,I L iI. 16111 m,tllldll•I .. .li0 <br /> GPS Latitude ; I O Closed <br /> O Hauler <br /> ----'.. J• .. O Inactive -- <br /> Longitude _ Q End-Use <br /> Q Planned <br /> ®New Tire Dealer O Auto Repair 0 Truckincg,neet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tine Dealer O Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station O Haulerriculture, <br /> Q Agriculture, Q Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility xi <br /> F PRC 42951-Waste Tire Hauler Re rstration and Trans mrt of Tire- <br /> 0 O PRC§42953-Contracts with Registered Wastcj•fitH i tauiws. <br /> O O PRC§42956-Registration/Decal in VeNc,10 <br /> lO O 14 CCR§18459 -Responsible Entities Complyinq with Manifesting Requirements <br /> IQ O 111 CCR§IW9.1 (a)(b)(r..)-Tire Program ID Number from CIWMB <br /> 10 O 14 CCR§18459,2.1 -Submittal of Manifest Forms and Tire Trip Lngs within 90 days <br /> .0 O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 yoars , <br /> c; <br /> CCR 184 <br /> 10 Q 14 § 60.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 O 14 CCR§18461 -Manifest Sy&tem Requirements for WaStti Tire End-Usti Facilities <br /> 0 O 14 CCR§18462.Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> !.00 Other: § <br /> -- --- __..- _-- ------- - -- .......... - <br /> Comments 7 <br /> �. l <br /> / 1 / <br /> j. _^l^fi�A1f � , 6208, <br /> INSTRUCTIONS ON BACK <br /> . Whl[c COOY:CIWMn Yellow Cory'flpaatn' Pink COD%/-LEA , <br /> J <br />