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ttfe Waste Tire Survey P P$ Inspection Report Inspection Report Number ■ <br /> '.r <br /> saMs181(°"'' Survey Form - Pae 1 1 0 - 1 01 3 5 75 <br /> CIWM8161(Nwr inaig Y g <br /> Calllamla IntpMW W.M.tAinae.m.nt Bwrd <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - Inspection Type (Fill one) <br /> x: OI Routine QRe-ins <br /> Re-inspection <br /> Q Referral Q Observation Suffi0 <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: San Jo�(��, y� l�tJl(w' O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> koake�2 Tr - I <br /> Physical Address k J 3 1 0- <br /> L4 0,;2('P <br /> ^J 1D CkA n ^ 9S49/,5 Inspection Date I ( , '? ' / 0 l//A, Time In Time Out t(i <br /> Business Rep TitleO AM O AM <br /> tt�� 11 D I S O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ! ! 0 Active !Passenger Generator 10 Outdoor <br /> Latitude O Q Closed Q Altered <br /> GP$ Q Hauler Q Indoor <br /> O i Q inactive ®Truck <br /> Longitude - 10 Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> i Q New Tire Dealer Q Auto Repair 0 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 r1wrok6thftlrftl ouk <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Violation O Extension <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> II ;Co�gpti�eQ tra <br /> O ! O PRC§42956-Registration/Decal in Vehicle ) { <br /> O 1 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date I € <br /> O O .14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB 1 J <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> IO Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O tie¢!Ctlfiftyl En3orreiaerlt <br /> O O <br /> 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities I::. .. ..'. c.�4 '•� a�w-, ,t." <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I: a � '• ' <br /> Other: § :"k ,m k nj+€ sra tea' <br /> Comments Ud _ jv15PEC M -f1105afe-.� t�10 I/�QS- <br /> Aadu_ _u . Gc,renr.. fz1 C _` EDTS Vi e�vt . �(C <br /> vlotgs e r _ �ervie� CbTs , e , No t&-es ^ 7e_� <br /> AWL If.' x-.... <br /> Inspection Form Included:Q <br /> — z� <br /> COMM( Q Az94No0D <br /> BusRep's Signature Phone 1 ors tfinature <br /> ber <br /> - <br /> INSTRUCTIONS ON BACK E VIA lM P lZ 2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0634704.0267 <br />