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u Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State mla Survey Form - Page 1 11 - 1 0 1 3 1 7 4 <br /> CIWMB 1Wast81(New 04/04) <br /> Cdlfornla Integrated Waete Management Board <br /> Part A-SurVev BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- _ D / Inspection Type (Fill one) <br /> Site Suffix: 7 J <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> Localn If Referral,choose referral type(Fill one) <br /> Identifier: gv, A Ye�h Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> � � U/� a..o�+}� Inspected By InspectorAV?H,-A <br /> Physical Address 3 <br /> 1693 Z7__ Loci-,�-c AL <br /> 9�33�J Inspection Date D aZ l 6 / 0 7 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Aa� �C1G(Si�lct ll�l `""yq� <br /> v Operational Status Tire Type Business Role Storage Type <br /> / <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t t <br /> 0 Active 0 Passenger 0 Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPs Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer !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 /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <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 <br /> -�� x ^ ? 7 <br /> Inspection Form Included:Q r <br /> Comments Included: � ��� <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK 'I I' �E JAIME P IL I E1 1 1[2131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 0708104.0044 <br />