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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Slate of California Survey Form - Page 1 - f 7 . 1 D 1 3 4 D 7 <br /> CNIMB 187(New 04104) <br /> California Integrated Waste Management Board <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / O O n _ Inspection Type (Fill one) <br /> Site Suffix: O( ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `.l/Y/'f�� <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> /r <br /> Inspected By Inspector 7/ /, <br /> Physical Address r' � / - 0 V '-"-CZ <br /> 1 as Larc). (Pd <br /> Kr &4 <br /> Inspection Date 0 g � � � � 06 <br /> Trac y ! <br /> L/`/• (�j I//�- Time In Time Out <br /> Business Rep Title O AM Q AM <br /> / n X il O PM QPM <br /> -- f Operational Status Tire Type Business Role Storage Type <br /> O (Fill one only) (Fill ah that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ! ! <br /> ®Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> it Business Type (Fill all that apply) i <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q 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 Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> (r• <br /> Y t <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires y; <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. +" <br /> Q Q PRC§42956-Registration/Decal in Vehicle ... pi <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements M� `•I <br /> 14 CCR§18459.1 a b c Tire Program ID Number from CIWMB f' <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 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 Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments //) -- n �i _11S Y(C� / $ ?RC1 1S Ott <br /> OF-#ae' /aczhons hr A . �`�%�/f�cf ` i�Ps cit pus � ur v��fYcs ate( <br /> ��idt:5_...rx'ffA u) 9 ✓ice, YUasfG jv pggl2.W1 I,Uent��i�//,�GCtW r+�cl O�sCL(�ed, <br /> r�iar re irr�tiov, + I►��x G�st,� d. s�ci�s� . r/v Vtvla*tIlks, <br /> OR cc) 1-4sof a) <br /> Inspection Form Included:Q p Q <br /> Comments Included: Q 751)" (" ,�q ' <br /> Busi R_ep'sSignature Phone Number Inspe Sign a Phone Number <br /> ■ INSTRUCTIONS ON ACK IEIXIRIMIPIL EI WX31 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br /> 0626304.0295 <br />