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i , Waste Tire Survey & Inspection Report Inspection Report Number <br /> sat.orcaurornm Survey Form - Page 1 I - 0 3 51 7 <br /> CIWMBted 10We7 ste(NewM0")0 <br /> eY <br /> lifomla Integraenegement Board <br /> PaftA-Survey_ BLUE OR BLACK INK PEN <br /> Business ProFlle j Inspection Details <br /> TPID- / -� q g � - Inspection Type (Fill one) <br /> Site Suffix: S ! 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local (� If Referral,choose referral type(Fill one) <br /> Identifier. JQw1C104FCt./� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business o ecility Name u - - <br /> / / Inspected By Inspectors <br /> Lo-I'/ n/f/� <br /> Physical Address/ 3 / S] ,d 39>/Yi*01/, <br /> // Inspection Date / / / 04 <br /> Time In Time Out <br /> Business Rep Title Q� 4P AM *AM <br /> f�'ral�GO � f l V G� Q PM J ( 0 PM <br /> Operatlonal 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 /> i Active Q Passenger &Generator is Outdoor <br /> Q Closed Q Altered <br /> GPS �� Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Busmen Type (Fill all that apply) - - - <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 /> 0 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 /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 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 114 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 /> Cottxnerdsa-44 Zc.Q � :b�Q.f_�s f V.I_e_(' 'Y�. aWi., /gF'lt <br /> two A 7 e //ry To <br /> Are X64 ta-1- y l e r '�► lam ," s vi"4�rr� <br /> Inspection Form Included:Q <br /> Comments Included:Q A� '- <br /> Business Rep's Signarur Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK 11FIXIAlAkIPIL El 111213162081 <br /> White Copy:CIWMB Yellow Copy.Operator Rnk Copy:LEA ® ■ <br /> 0617904.0406 <br />