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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> cteSteteof California Survey Form - Page 1 1 4 - 1 4 0 6 5 2 <br /> isf(tlew <br /> California Integgra-ted Waste Mana..gege <br /> ment Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- y n / - ^ inspection Type (Fill one) <br /> fFl <br /> Site Suffix: I r c! RoutineQ Re-inspection p Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: _Qv_ z4atie..e I�- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ -- <br /> Inspected By Inspector <br /> ��a-�� /rte s������' ��•� I� <br /> Physical Address 3 9 - D <br /> a y/" Z-V I-,'re 7411� <br /> L Inspection Date <br /> per J r <br /> Time In Time Out <br /> Business Rep TitleO AM / AM <br /> t /��GLIr VAte O PM / / (D QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> ThLatitude e Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r i Active Q Passenger 0 Generator QFOutdoor <br /> O Q Closed Q Altered /v <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader O Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer 0 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@1d11rAiT7,, <br /> Notice Of violation Q Evension. <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. IlaSt attlE�+ 3 <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§1B459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days ¢ J <br /> O 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 (s - <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 4e r •T1 d/ ,y Ata-I' Q,r- r%,-r'e- uvajA ryf j; 0e- <br /> 9 4%y tares gyp/ •e -a! l-t <br /> Inspection Form Included:O /r`G �* W �p <br /> Comments Included:Q <br /> Re 's ure Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI 111213162081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® . <br /> 0628404,00717 <br />