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Ff4 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate of California R <br /> Cgrated asteManag 1 Survey Form - Page 1 1 1 . 1 0 2 5 6 6 3 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile 1 Inspection Details <br /> TPID- Inspection O y Inspection Type (Fill one) <br /> Site Suffix: 1 7, / 0 Routine ®Re-inspection 0 Referral 0 Observation <br /> Local If Referraf,choose referral type(Fill one) <br /> Identifier: lf5l�r q Mth „�-�^" �f'S 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name r <br /> Inspected By Inspector <br /> 0,91-Address �r�dis �Phy 3 C/ - I v / 61 <br /> inspection Date D3 I Z Z I © C <br /> I Time In Time Out <br /> I Business Rep Title Q AM 0 AM <br /> J.a,e� 0 PM O PM <br /> "ticks L-arrw%6Ce- � '�� Operational Status Tire TypegeType <br /> Business Role Stora <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger *Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive ®Truck <br /> Longitude - <br /> 9 I D Planned 0 OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Govemment 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFOF�ICLMNT ST�1Tli3 <br /> HAULING�kNi? N1FkgT REQUIREMSAIT& T <br /> —� 0 Native Of Violet[on 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. C9lnpllance Deadline <br /> 0 0 PRC§42956-RegistrationJDecal in Vehicle i <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB t� <br /> 0 0 +14 CCR§ 18459.2.1 -Submitta.of Manifest Forms and Tire Trip Logs within 90 clays (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers ` fijnf (CIWCVtB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 . 0 14 CCR§ 1B462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r <br /> f��iffagca . No Vlalagoos <br /> 0 L`-! Other: § - / _—} — ---_ <br /> Comments CA C45z-(r) <br /> {c S LA (� 4 <br /> L�., 4-vjL7 4,,_ <br /> LALel�' yf c' � p .15 <br /> I // Is n 'r <br /> -inspection Form Included: 0 Z �-Z��b <br /> Comments Included: - b <br /> usine ep's Signature Phone Number 1 e o signature Phone Number <br /> INSTRUCTIONS ON B ��iptT1!lr lf� -: V1 �L .X�f�►��'1 L�Ei iri3� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA + <br />