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Waste Tire y & Inspection Repc Inspection Report Number <br /> state B81CaliforniaN I 1 — 1141286 <br /> Cgrated Waste <br /> eManag ) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: © ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �L. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> BuslIinlIess or Facility Name Inspected By Inspector <br /> All M%YA vans Mivxi ueG1L N D&Illy rifle 2 � - <br /> Physical Address V Q /61W <br /> Chap lfr c,)" <br /> Inspection Date 9 <br /> Time In Time Out <br /> Business Rep Title O AM �j O AM <br /> ® PM PM <br /> tAah <br /> __ _ _ _ _ �/KJ�e r �CJ� ! � ®Ma �c`� - -- - - -- <br /> (Fill Ione only) (Fill all that apply) Business Role Storage Type <br /> - -- - - - Operational Status Tire Type <br /> O (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> Q Closed ® Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ® 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 <br /> 1� �►�JL,. GSM., 111 QU( EE, .F. �. .�. ,t. ii iro <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 /> R <br /> > s � 9 <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 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days � " , <br /> i N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers e <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 <br /> Other: § <br /> Comments <br /> cry- <br /> Inspection Form Included: Q �ro O t _ I CQ�� (� <br /> Comments Included: Q - - --- - ----+- --\— --- l - - ---G- 6�� <br /> Business Rep natur Phone Number -Insp or Si nature Phone Number <br /> ` 62081 <br /> INSTRUCTIONS ON BACK mC lrre. cot� ��� �# rk FT 2T3 <br /> White Co B Yellow Copy:Operator Pink Copy:LEA <br />