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i;; <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State mcaia111 Survey Form - Page 1 1 5 - 1 0 0 6 4 9 5 <br /> C.mB ,(N-04/04) <br /> CalHomla Intgegrated WadaeManagement Board - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID - Q ` Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral. Q Observation <br /> Local If Referral,choose referral type(Fill one) I . <br /> Identifier: Q CHP Q CIWMB Q Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name <br /> AAL'+�1 C."? Inspected By Inspector <br /> Physical Address <br /> �� L �S�� Inspection Date � -6 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> D S Closed Q Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> O 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 Dismander 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 /> Q 1 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 \�y e-6 <br /> _ --j- \10 <br /> _ _ <br /> Inspection Form Included:Q <br /> Comments Included:Q - — <br /> Business Rep's Signature Phone Number cto ure Phone Number <br /> ff 62081 <br /> INSTRUCTIONS ON BACK <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy LEA ® ■ <br /> 0529204. 1183 <br />