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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State o'California Survey Form - Page 1 i 1 - 1 01 3 61 2 <br /> Cgral 181(New nag <br /> California4104) <br /> InlegratW Weab Managemerrt Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details _J <br /> TPID / 6 3 ^ - D Inspection Type (Fill one) <br /> Site Suffix: /Y IS Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SA C V ,0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name !u� Inspected By Inspector <br /> Lam ` - / m / �a.4Q„>, ,OV- <br /> 42/,Z <br /> Inspection Date C) <br /> 7 Time In Time Out O <br /> Business Rep Title / IJO `M i AM <br /> O PM l / —3O PM <br /> Operational Status j Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ' 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed ! 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive j 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 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 <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <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 <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <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 <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 1 Other: § / r� <br /> Comments J4j „/__ see-, /df �Y/7(_�,-< <br /> AC-0711C <br /> �a <br /> Co A *- WA*?'� 4Cl""'t <br /> Inspection Form Included:O (�� ��3 30n <br /> Commets Included: - <br /> ah'�' <br /> Business Rep'Y Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK 10XIAIMIPILIE1 111213 62081 <br /> ■ Whde Copy.CIWMB Yellow Copy:Operator Pink Copy:LFA ® . <br /> 0618604.0024 <br />