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u=n Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State or earsornla 1 7 1 01 31 4 7 <br /> t:g.tBst(N.w oUo1) Survey Form - Page 1 <br /> CalHornla MLgnted Waata Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / t7 _ / Inspection Type (Fill one) <br /> Site Suffix:- G 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S' <br /> r��•a-aci"7., �-��— Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> YInspector <br /> Physical Address -} - / / u/3l30 j A" AD✓fit <br /> 3 d 63 �e-��ya.•r e�.�' <br /> Inspection Date D / 0 3 , Q 7 <br /> f / Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status I Tire Type Business Role Storage Type <br /> Tire Count(Whole/Pi (Fill one only) (Fill all that appy), (Fill all that apply) (Fill all that apply) <br /> ' 49 Active Q Passenger 0 Generator 10 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive *Truck <br /> LongitudeQ Planned Q OTR- Q Q End-Use Container <br /> I <br /> rBusiness 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer Generator Hauler and End-Use FacilityNFORiI+lfYNT§TArfiS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Tai ispurl of Tires Notice f?t Violation d F�therrsIon <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> I I <br /> Q Q �ComptCa'nceDeadline { <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB 4 -L _,-1• <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 v. <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators - -- <br /> Q Q Other § W <br /> Comments - <br /> ,LGt,itry?� ,�CP�Sfi.•t 'Y'L�+� Cf:-{�_c;L,.cfi' flu ��G'c�t:u:� �.t� i./tcoVE'�.�'I. <br /> GxC r 17 W 2,,C /-ra✓/t CJ..Cfu. <br /> d'/'V/rte/ <br /> %L '1 V'. 'c�.:c sr c1�o/.-, re -* d'/'V Ax, <br /> Inspection Form included:Q <br /> Comments Included:Q- <br /> B nese Vers s nat Phone Number Inspectors Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK IEIXIAIMIPILIEI 111213162081 <br /> White Copy:CIWMB Yallow Copy:Operator Pink Copy:LEA ® ■ <br /> 0703804.0495 <br />